Researchers at the 2008 American College of Rheumatology meeting reported that 47% of patients who cannot tolerate oral bisphosphonates are infected with H. pylori, as are 83% of systemic sclerosis (SSc) patients.1,2 They suggest that testing for and treating the infection might enable more patients to take oral bisphosphonates and might reduce some of the gastrointestinal problems common in SSc.
“Too often we attribute symptoms to drugs without considering other causes. Managing H. pylori not only can treat the dyspepsia but may reduce the risk of peptic ulcers if the patient eventually requires NSAIDs for osteoporotic fractures or other reasons.”—Rupert W. Leong, MD
Robert Koval, MD, and colleagues from the University of Colorado Denver Health Sciences Center in Denver, Colorado, examined the H. pylori status of a series of 95 patients who either did or did not have gastrointestinal intolerance for oral bisphosphonates. They found that 47% of those who were gastrointestinal-intolerant were H. pylori positive.“Patients who are intolerant of oral bisphosphonates are significantly more likely to be H. pylori positive. The cost difference between oral and intravenous administration of bisphosphonates is considerable, with a potential savings of $5772 per patient, per year of treatment. Treatment for H. pylori using standard therapy results in >90% eradication. Thus further studies should evaluate whether treatment of H. pylori in those patients intolerant of oral bisphosphonates may result in re-introduction/tolerance of the drug, resulting in improved quality of life and significant healthcare savings,” Dr. Koval said.
Major cost savings might be possible by eliminating H. pylori in the oral bisphosphonate-intolerant
The investigators noted that about 15% of those receiving bisphosphonates were unable to tolerate the drugs due to gastrointestinal side effects. Koval et al hypothesized that H. pylori contributes to oral bisphosphonate intolerance, and that a cost analysis “would suggest profound financial implications for reintroduction of oral versus intravenous bisphosphonates following the treatment of this disease.”
This study enrolled 95 consecutive patients with osteoporosis treated with an intravenous bisphosphonate. Patients were subdivided into those with gastrointestinal intolerance necessitating intravenous bisphosphonates versus those with no gastrointestinal intolerance but who had a contraindication for oral bisphosphonate use such as a history of esophageal cancer or bariatric surgery. The researchers used SciMedix® H. pylori serum antibody kits to determine H. pylori status of all patients. They calculated the potential yearly savings of oral versus intravenous bisphosphonates using Medicare rates and pharmaceutical costs for Colorado.
Dr. Koval reported, “Of the 56 patients who were gastrointestinal intolerant, 25 (47%) were H. pylori positive. Of the 39 patients with no gastrointestinal intolerance, only 10 were H. pylori positive (27%, P = .0462). The presence of nonulcer dyspepsia prior to initiation of oral bisphosphonate did not predict who will have an H. pylori infection.” He said that early results show that three of the first five patients treated for H. pylori were able to resume oral bisphosphonates. “Depending on the intravenous bisphosphonate used, avoiding its use results in an average cost savings of up to $5772 per patient, per year,” he said.
Researchers suspect H. pylori of adding to gastric woes in SSc
Olga L. Vera-Lastra, MD, and colleagues from the Instituto Mexicano del Seguro Social in Mexico City, Mexico, suspect that major benefits might come from treating H. pylori in patients with systemic sclerosis, up to 90% of whom have gastrointestinal problems. Dr. Vera-Lastra pointed out that altered peristalsis in SSc encourages H. pylori infection.
These investigators studied clinical, endoscopic, manometric and histologic gastro-esophageal manifestations and prevalence of H. pylori infection in 60 patients with SSc. The presence of H. pylori was investigated by gastric biopsy, which showed that 83% of these patients were infected.
Translating research into practice
Both research teams pointed to the need for more research on H. pylori in these populations, but some experts suspect that clinicians might not wait long before translating some of this research into practice.
Rupert W. Leong, MD, an expert on drug-induced GI side effects, told MSKreport.com that the Koval study is “an excellent abstract and may actually alter management in the rheumatology world.”
“Too often we attribute symptoms to drugs without considering other causes. Managing H. pylori not only can treat the dyspepsia but may reduce the risk of peptic ulcers if the patient eventually requires NSAIDs for osteoporotic fractures or other reasons,” said Dr. Leong, who is in the department of gastroenterology and hepatology at Bankstown-Lidcombe Hospital in Sydney, Australia.
References
1. Koval R, West S, Wickersham P. Helicobacter pylori infection and gastrointestinal intolerance to oral bisphosphonates. Presented at the American College of Rheumatology 2008 meeting, San Francisco, October 28, 2008. Presentation no. 1546.
2. Vera-Lastra OL, Santos-Navarro R, Mendez R. Clinical, endoscopic, manometric, histologic findings in the gastro-esophageal tract and prevalence of Helicobacter pylori in patients with systemic sclerosis. Presented at the American College of Rheumatology 2008 meeting; San Francisco, CA; October 28, 2008. Presentation 1786.
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