CAVEATS: Drug resistance, previous Tx could skew results
This meta-analysis only included studies performed in Italy, although 2 of the trials did include US recruits. Drug resistance patterns may be different in this country, which could alter sequential therapy’s eradication rates.
Because 3 antibiotics are used in sequential therapy, we may have fewer remaining options for patients who do not respond to this regimen, and we do not have information about patients with previous treatment failures. In addition, this meta-analysis only evaluated H pylori eradication rates in treatment-naïve patients, so we have no information about the effectiveness of this regimen in patients with previous treatment failures.
Would other sequential regimens—or drugs—work?
Patients who are allergic to amoxicillin would not be candidates for this sequential therapy protocol. While sequential therapy was compared with 7- to 10-day standard triple therapy, this study did not compare it with other regimens—eg, quadruple therapy or a 14-day course of standard triple-drug therapy.
Other drugs may also affect outcomes. The sequential therapy studies all used tinidazole, a relatively new agent in the United States; we don’t know whether metronidazole or other imidazoles are as effective.
The authors of this meta-analysis also noted the possibility of publication bias, but we doubt that there are enough unpublished data to invalidate the findings. Also, the selected RCTs only addressed eradication rates and not patient-oriented outcomes. However, most patient-oriented outcomes, including cancer and ulcers, can take years, even decades, to develop.
CHALLENGES TO IMPLEMENTATION: Sequential therapy may be confusing
While adherence rates were similar in the standard and sequential treatment groups in the meta-analysis, sequential therapy—which requires switching medications midway through treatment—might be more confusing for patients in actual practice. This has the potential to negatively affect adherence to the sequential regimen.
It will be important for physicians who prescribe sequential therapy to counsel patients on the importance of completing the treatment regimen exactly as prescribed and to provide clear instructions for doing so, ideally in the form of a patient handout like the one on page 653. Cost is not a problem; the price of sequential therapy is about equal to, or possibly less than, that of standard therapy.5
This study was selected and evaluated using FPIN’s Priority Updates from the Research Literature (PURL) Surveillance System methodology. The criteria and findings leading to the selection of this study as a PURL can be accessed at www.jfponline.com/purls.
