Journal of Pediatric Gastroenterology & Nutrition:
Letters to the Editor
How Often Do You Fail to Take All of Your Medication?
Francavilla, Ruggiero*; Zullo, Angelo†; Vaira, Dino‡
*University of Bari, Bari
†Nuovo Regina Margherita, Hospitalí, Rome
‡University of Bologna, Bologna, Italy
To the Editor:
We read with interest the article by Prieto-Jimenez et al (1); however, the conclusion overlooks the problem of adherence to treatment. A success rate of 44% has never been reported since dual therapies were introduced or in more recent pediatric trials. Compliance is the most important factor predicting treatment success (2), and eradication rates of 20% were reported in those taking <60% of pills (3).
In the El Paso children, several indicators of poor adherence are present: treatment of asymptomatic disease, side effects/bad taste of medication, patient's lack of belief in the benefits of treatment and of insight into the illness, complexity of treatment and possibility of receiving placebo, patients not asking for medical advice, and low income (4).
That compliance was suboptimal is confirmed by a second article on the same cohort aiming at assessing iron stores after Helicobacter pylori treatment (5). How do the authors explain that after 6 months of iron administration, ferritin levels only showed a minimal increase after H pylori eradication? A similar experience revealed that in 2 months, children who received iron plus eradication doubled their ferritin content. (6) Perhaps, as in the case of antibiotics, they were poorly adherent to iron therapy. We have employed the sequential regimen to treat >200 children with an eradication rate >85% (7). Our data have been confirmed by a recent meta-analysis (eradication rate of 90.7%; 95% confidence interval 83.8%–94.9%) (8).
Adherence is a primary determinant of treatment efficacy. When treatment outcome is markedly lower than expected, the key to the reading may well be the question “how often do you fail to take all your medication?”
1. Prieto-Jimenez CA, Cardenas VM, Fischbach LA, et al. Double-blind randomized trial of quadruple sequential Helicobacter pylori eradication therapy in asymptomatic infected children in El Paso, Texas. J Pediatr Gastroenterol Nutr 2011; 52:319–325.
2. Graham D, Lew GM, Malaty HM, et al. Factors influencing the eradication of Helicobacter pylori with triple therapy. Gastroenterology 1992; 102:493–496.
3. Wermeille J, Dederding JP, Cunningham M, et al. Failure of Helicobacter pylori eradication in an ambulatory population: is poor compliance the main cause? Digestion 1998; 59 (suppl 3):437.
4. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005; 353:487–497.
5. Cardenas VM, Prieto-Jimenez CA, Mulla ZD, et al. Helicobacter pylori eradication and change in markers of iron stores among non-iron-deficient children in El Paso, Texas: an etiologic intervention study. J Pediatr Gastroenterol Nutr 2011; 52:326–333.
6. Choe YH, Kim SK, Son BK, et al. Randomized placebo-controlled trial of Helicobacter pylori eradication for iron-deficiency anemia in preadolescent children and adolescents. Helicobacter 1999; 4:135–139.
7. Francavilla R, Lionetti E, Cavallo L. Sequential treatment for Helicobacter pylori eradication in children. Gut 2008; 57:1178.
8. Gatta L, Vakil N, Leandro G, et al. Sequential therapy or triple therapy for Helicobacter pylori infection: systematic review and meta-analysis of randomized controlled trials in adults and children. Am J Gastroenterol 2009; 104:3069–3079.
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