A Prediction Model for Successful Increase of Adalimumab Dose Intervals in Patients with Crohn's Disease: Secondary Analysis of the Pragmatic Open-Label Randomised Controlled Non-inferiority LADI Trial

BACKGROUND

In the pragmatic open-label randomised controlled non-inferiority LADI trial we showed that increasing adalimumab (ADA) dose intervals was non-inferior to conventional dosing for persistent flares in patients with Crohn's disease (CD) in clinical and biochemical remission.

AIMS

To develop a prediction model to identify patients who can successfully increase their ADA dose interval based on secondary analysis of trial data.

METHODS

Patients in the intervention group of the LADI trial increased ADA intervals to 3 and then to 4 weeks. The dose interval increase was defined as successful when patients had no persistent flare (> 8 weeks), no intervention-related severe adverse events, no rescue medication use during the study, and were on an increased dose interval while in clinical and biochemical remission at week 48. Prediction models were based on logistic regression with relaxed LASSO. Models were internally validated using bootstrap optimism correction.

RESULTS

We included 109 patients, of which 60.6% successfully increased their dose interval. Patients that were active smokers (odds ratio [OR] 0.90), had previous CD-related intra-abdominal surgeries (OR 0.85), proximal small bowel disease (OR 0.92), an increased Harvey-Bradshaw Index (OR 0.99) or increased faecal calprotectin (OR 0.997) were less likely to successfully increase their dose interval. The model had fair discriminative ability (AUC = 0.63) and net benefit analysis showed that the model could be used to select patients who could increase their dose interval.

CONCLUSION

The final prediction model seems promising to select patients who could successfully increase their ADA dose interval. The model should be validated externally before it may be applied in clinical practice.

CLINICAL TRIAL REGISTRATION NUMBER

ClinicalTrials.gov, number NCT03172377.

Cost-Effectiveness Analysis of Increased Adalimumab Dose Intervals in Crohn's Disease Patients in Stable Remission: The Randomized Controlled LADI Trial

BACKGROUND AND AIMS

We aimed to assess cost-effectiveness of increasing adalimumab dose intervals compared to the conventional dosing interval in patients with Crohn's disease [CD] in stable clinical and biochemical remission.

DESIGN

We conducted a pragmatic, open-label, randomized controlled non-inferiority trial, comparing increased adalimumab intervals with the 2-weekly interval in adult CD patients in clinical remission. Quality of life was measured with the EQ-5D-5L. Costs were measured from a societal perspective. Results are shown as differences and incremental net monetary benefit [iNMB] at relevant willingness to accept [WTA] levels.

RESULTS

We randomized 174 patients to the intervention [n = 113] and control [n = 61] groups. No difference was found in utility (difference: -0.017, 95% confidence interval [-0.044; 0.004]) and total costs (-€943, [-€2226; €1367]) over the 48-week study period between the two groups. Medication costs per patient were lower (-€2545, [-€2780; -€2192]) in the intervention group, but non-medication healthcare (+€474, [+€149; +€952]) and patient costs (+€365 [+€92; €1058]) were higher. Cost-utility analysis showed that the iNMB was €594 [-€2099; €2050], €69 [-€2908; €1965] and -€455 [-€4,096; €1984] at WTA levels of €20 000, €50 000 and €80 000, respectively. Increasing adalimumab dose intervals was more likely to be cost-effective at WTA levels below €53 960 per quality-adjusted life year. Above €53 960 continuing the conventional dose interval was more likely to be cost-effective.

CONCLUSION

When the loss of a quality-adjusted life year is valued at less than €53 960, increasing the adalimumab dose interval is a cost-effective strategy in CD patients in stable clinical and biochemical remission.

CLINICAL TRIAL REGISTRATION NUMBER

ClinicalTrials.gov, number NCT03172377.

The Effectiveness and Safety of First-Line Thioguanine in Thiopurine-Naïve Inflammatory Bowel Disease Patients

BACKGROUND

Currently thioguanine is solely used as treatment for inflammatory bowel disease after azathioprine and/or mercaptopurine failure. This study aimed to determine the safety, effectiveness, and 12-month drug survival of thioguanine in thiopurine-naïve patients with inflammatory bowel disease.

METHODS

A retrospective cohort study was performed in thiopurine-naïve patients with inflammatory bowel disease treated with thioguanine as first thiopurine derivate. Clinical effectiveness was defined as the continuation of thioguanine without the (re)initiation of concurrent biological therapy, systemic corticosteroids, or a surgical intervention. All adverse events were categorized by the Common Terminology Criteria for Adverse Events.

RESULTS

A total of 114 patients (male 39%, Crohn's disease 53%) were included with a median treatment duration of 25 months and a median thioguanine dosage of 20 mg/d. Clinical effectiveness at 12 months was observed in 53% of patients, and 78% of these responding patients remained responsive until the end of follow-up. During the entire follow-up period, 26 patients were primary nonresponders, 8 had a secondary loss of response, and 11 patients were unable to cease therapy with systemic corticosteroids within 6 months and were therefore classified as nonresponders. After 12 months, thioguanine was still used by 86% of patients. Fifty (44%) patients developed adverse events (grade 1 or 2) and 9 (8%) patients ceased therapy due to the occurrence of adverse events. An infection was documented in 3 patients, none of them requiring hospitalization and pancytopenia occurred in 2 other patients. No signs of nodular regenerative hyperplasia or portal hypertension were observed.

CONCLUSIONS

At 12 months, first-line thioguanine therapy was clinically effective in 53% of thiopurine-naïve inflammatory bowel disease patients with an acceptable safety profile.

Early At-Home Measurement of Adalimumab Concentrations to Guide Anti-TNF Precision Dosing: A Pilot Study

BACKGROUND AND OBJECTIVE

Underdosing of adalimumab can result in non-response and poor disease control in patients with rheumatic disease or inflammatory bowel disease. In this pilot study we aimed to predict adalimumab concentrations with population pharmacokinetic model-based Bayesian forecasting early in therapy.

METHODS

Adalimumab pharmacokinetic models were identified with a literature search. A fit-for-purpose evaluation of the model was performed for rheumatologic and inflammatory bowel disease (IBD) patients with adalimumab peak (first dose) and trough samples (first and seventh dose) obtained by a volumetric absorptive microsampling technique. Steady state adalimumab concentrations were predicted after the first adalimumab administration. Predictive performance was calculated with mean prediction error (MPE) and normalised root mean square error (RMSE).

RESULTS

Thirty-six patients (22 rheumatologic and 14 IBD) were analysed in our study. After stratification for absence of anti-adalimumab antibodies, the calculated MPE was -2.6% and normalised RMSE 24.0%. Concordance between predicted and measured adalimumab serum concentrations falling within or outside the therapeutic window was 75%. Three patients (8.3%) developed detectable concentrations of anti-adalimumab antibodies.

CONCLUSION

This prospective study demonstrates that adalimumab concentrations at steady state can be predicted from early samples during the induction phase.

CLINICAL TRIAL REGISTRATION

The trial was registered in the Netherlands Trial Register with trial registry number NTR 7692 ( www.trialregister.nl ).

Increased versus conventional adalimumab dose interval for patients with Crohn's disease in stable remission (LADI): a pragmatic, open-label, non-inferiority, randomised controlled trial

BACKGROUND

Despite its effectiveness in treating Crohn's disease, adalimumab is associated with an increased risk of infections and high health-care costs. We aimed to assess clinical outcomes of increased adalimumab dose intervals versus conventional dosing in patients with Crohn's disease in stable remission.

METHODS

The LADI study was a pragmatic, open-label, multicentre, non-inferiority, parallel, randomised controlled trial, done in six academic hospitals and 14 general hospitals in the Netherlands. Adults (aged ≥18 years) diagnosed with luminal Crohn's disease (with or without concomitant perianal disease) were eligible when in steroid-free clinical and biochemical remission (defined as Harvey-Bradshaw Index [HBI] score <5, faecal calprotectin <150 μg/g, and C-reactive protein <10 mg/L) for at least 9 months on a stable dose of 40 mg subcutaneous adalimumab every 2 weeks. Patients were randomly assigned (2:1) to the intervention group or control group by the coordinating investigator using a secure web-based system with variable block randomisation (block sizes of 6, 9, and 12). Randomisation was stratified on concomitant use of thiopurines and methotrexate. Patients and health-care providers were not masked to group assignment. Patients allocated to the intervention group increased adalimumab dose intervals to 40 mg every 3 weeks at baseline and further to every 4 weeks if they remained in clinical and biochemical remission at week 24. Patients in the control group continued their 2-weekly dose interval. The primary outcome was the cumulative incidence of persistent flares at week 48 defined as the presence of at least two of the following criteria: HBI score of 5 or more, C-reactive protein 10 mg/L or more, and faecal calprotectin more than 250 μg/g for more than 8 weeks and a concurrent decrease in the adalimumab dose interval or start of escape medication. The non-inferiority margin was 15% on a risk difference scale. All analyses were done in the intention-to-treat and per-protocol populations. This trial was registered at ClinicalTrials.gov, NCT03172377, and is not recruiting.

FINDINGS

Between May 3, 2017, and July 6, 2020, 174 patients were randomly assigned to the intervention group (n=113) or the control group (n=61). Four patients from the intervention group and one patient from the control group were excluded from the analysis for not meeting inclusion criteria. 85 (50%) of 169 participants were female and 84 (50%) were male. At week 48, the cumulative incidence of persistent flares in the intervention group (three [3%] of 109) was non-inferior compared with the control group (zero; pooled adjusted risk difference 1·86% [90% CI -0·35 to 4·07). Seven serious adverse events occurred, all in the intervention group, of which two (both patients with intestinal obstruction) were possibly related to the intervention. Per 100 person-years, 168·35 total adverse events, 59·99 infection-related adverse events, and 42·57 gastrointestinal adverse events occurred in the intervention group versus 134·67, 75·03, and 5·77 in the control group, respectively.

INTERPRETATION

The individual benefit of increasing adalimumab dose intervals versus the risk of disease recurrence is a trade-off that should take patient preferences regarding medication and the risk of a flare into account.

FUNDING

Netherlands Organisation for Health Research and Development.

Exposure to thioguanine during 117 pregnancies in women with inflammatory bowel disease

BACKGROUND

Safety of thioguanine in pregnant patients with inflammatory bowel disease (IBD) is sparsely recorded. This study was aimed to document the safety of thioguanine during pregnancy and in birth.

METHODS

In this multicenter case series, IBD patients treated with thioguanine during pregnancy were included. Data regarding disease and medication history, pregnancy course, obstetric complications and neonatal outcomes were collected.

RESULTS

Data on 117 thioguanine-exposed pregnancies in 99 women were collected. Most (78%) had Crohn's disease and the mean age at delivery was 31 years. In eighteen pregnancies (15%) IBD flared. Obstetric and infectious complications were seen in 15% (n=17) and 7% (n=8) of pregnancies, respectively. Ten pregnancies (8.5%) resulted in a first trimester miscarriage and one in a stillbirth at 22 weeks gestational age. Congenital abnormalities were observed in one induced abortion (trisomy 21) and in one of the live-born children (cleft palate) . In total 109 neonates were born from 101 singleton pregnancies and 4 twin pregnancies. In the singleton pregnancies, ten children were born prematurely and ten were born small for gestational age. Screening for myelosuppresion was performed in sixteen neonates (14.7%); two had anemia in umbilical cord blood. All outcomes were comparable to either the general Dutch population or to data from 3 Dutch cohort studies on the use of conventional thiopurines in pregnant IBD patients.

CONCLUSION

In this large case series the use of thioguanine during pregnancy is not associated in excess with adverse maternal or neonatal outcomes.

Relationship Between Thiopurine S-Methyltransferase Genotype/Phenotype and 6-Thioguanine Nucleotide Levels in 316 Patients With Inflammatory Bowel Disease on 6-Thioguanine

BACKGROUND

In inflammatory bowel disease (IBD), conventional thiopurine users cease treatment in 60% of cases within 5 years, mostly because of adverse events or nonresponse. In this study, the authors aimed to investigate the role of 6-thioguanine nucleotide (TGN) measurements, geno/phenotyping of thiopurine S-methyltransferase (TPMT), and their mutual relationship with TG therapy in IBD.

METHODS

An international retrospective, multicenter cohort study was performed at 4 centers in the Netherlands (Máxima Medical Centre) and the United Kingdom (Guy's and St. Thomas' Hospital, Queen Elizabeth Hospital, and East Surrey Hospital).

RESULTS

Overall, 526 6-TGN measurements were performed in 316 patients with IBD. The median daily dosage of TG was 20 mg/d (range 10-40 mg/d), and the median duration of TG use was 21.1 months (SD, 28.0). In total, 129 patients (40.8%) had a known TPMT status. In the variant-type and wild-type TPMT genotype metabolism groups, median 6-TGN values were 1126 [interquartile range (IQR) 948-1562] and 467.5 pmol/8 × 10E8 red blood cells (RBCs) (IQR 334-593). A significant difference was observed between the 2 groups (P = 0.0001, t test). For TPMT phenotypes, in the slow, fast, and normal metabolism groups, the median 6-TGN values were 772.0 (IQR 459-1724), 296.0 (IQR 200-705), and 774.5 pmol/8 × 10E8 RBCs (IQR 500.5-981.5), with a significant difference observed between groups (P < 0.001, analysis of variance).

CONCLUSIONS

Our findings indicated that TPMT measurements at TG initiation can be useful but are not necessary for daily practice. TPMT genotypes and phenotypes are both associated with significant differences in 6-TGN levels between metabolic groups. However, the advantage of TG remains that RBC 6-TGN measurements are not crucial to monitor treatments in patients with IBD because these measurements did not correlate with laboratory result abnormalities. This presents as a major advantage in countries where patients cannot access these diagnostic tests.

Clinical Outcomes of Covid-19 in Patients With Inflammatory Bowel Disease: A Nationwide Cohort Study

BACKGROUND AND AIMS

The COVID-19 risk and disease course in inflammatory bowel disease [IBD] patients remains uncertain. Therefore, we aimed to assess the clinical presentation, disease course, and outcomes of COVID-19 in IBD patients. Second, we determined COVID-19 incidences in IBD patients and compared this with the general population.

METHODS

We conducted a multicentre, nationwide IBD cohort study in The Netherlands and identified patients with COVID-19. First, we assessed the COVID-19 disease course and outcomes. Second, we compared COVID-19 incidences between our IBD study cohort and the general Dutch population.

RESULTS

We established an IBD cohort of 34 763 patients. COVID-19 was diagnosed in 100/34 763 patients [0.29%]; 20/100 of these patients [20%] had severe COVID-19 defined as admission to the intensive care unit, mechanical ventilation, and/or death. Hospitalisation occurred in 59/100 [59.0%] patients and 13/100 [13.0%] died. All patients who died had comorbidities and all but one were ≥65 years old. In line, we identified ≥1 comorbidity as an independent risk factor for hospitalisation (odds ratio [OR] 4.20, 95% confidence interval [CI] 1.58-11.17,; p = 0.004). Incidences of COVID-19 between the IBD study cohort and the general population were comparable (287.6 [95% CI 236.6-349.7] versus 333.0 [95% CI 329.3-336.7] per 100000 patients, respectively; p = 0.15).

CONCLUSIONS

Of 100 cases with IBD and COVID-19, 20% developed severe COVID-19, 59% were hospitalised and 13% died. A comparable COVID-19 risk was found between the IBD cohort [100/34 763 = 0.29%] and the general Dutch population. The presence of ≥1 comorbidities was an independent risk factor for hospitalisation due to COVID-19.

Switching from infliximab innovator to biosimilar in patients with inflammatory bowel disease: a 12-month multicentre observational prospective cohort study

BACKGROUND

Infliximab biosimilars have become available for treatment of inflammatory bowel disease (IBD). However, data showing long-term safety and effectiveness of biosimilars in IBD patients are limited.

AIM

To study prospectively the switch from infliximab innovator to biosimilar in an IBD cohort with 12 months follow-up to evaluate safety and effectiveness.

METHODS

Adult IBD patients from two hospitals treated with infliximab innovator (Remicade; Janssen Biotech,  Horsham ,  Pennsylvania, USA) were switched to infliximab biosimilar (Inflectra; Hospira, Lake Forest, Illinois, USA) as part of routine care, but in a controlled setting. Blood samples were taken just before the first, second, fourth and seventh infusion of biosimilar. Infliximab trough levels, antibodies-to-infliximab (ATI), CRP and ESR were measured and disease activity scores were calculated.

RESULTS

Our cohort consisted of 133 IBD patients (64% CD, 36% UC). Before switching we found widely varying infliximab levels (median 3.5 μg/mL). ATI were detected in eight patients (6%). Most patients were in remission or had mild disease (CD: 82% UC: 90%). After switching to biosimilar, 35 patients (26%) discontinued therapy within 12 months, mostly due to subjective higher disease activity (9%) and adverse events (AE, 9.8%). AE included general malaise/fatigue (n = 7), arthralgia (n = 2), skin problems (n = 2) and infusion reactions (n = 2). No differences in IFX levels, CRP, and disease activity scores were found between the four time points (P ≥ .0917).

CONCLUSIONS

We found no differences in drug levels and disease activity between infliximab innovator and biosimilar in our IBD cohort, indicating that biosimilars are safe and effective. The high proportions of discontinuers were mostly due to elective withdrawal or subjective disease worsening.

Functional bowel symptoms in a general Dutch population and associations with common stimulants

BACKGROUND

Functional gastrointestinal symptoms are often felt to be related to the use of alcohol, coffee and smoking.

METHODS

A random sample of 500 adults was interviewed by telephone about their gastrointestinal symptoms and the use of alcohol, coffee and smoking. Dyspepsia and irritable bowel syndrome (IBS) were defined using common, internationally used criteria.

RESULTS

Of those invited, 85.4% agreed to participate (43.5% male). Of the participants 21.4% had gastrointestinal symptoms >6 times/last year, 13.8% had dyspepsia, and 5.8% had IBS, the latter being more common among women. Of the men, 83.9% reported alcohol consumption, 92.0% drank coffee, and 52.2% smoked. Of the women 62.4% drank alcohol, 88.1% drank coffee and 29.8% smoked. Use of alcohol or coffee was not related to dyspepsia. Current smokers had a 2.3-fold increased risk (P=0.02) and former smokers a 2.7 increased risk (P=0.009) for dyspepsia compared to never smokers. No association between IBS and use of alcohol, coffee or smoking could be demonstrated.

CONCLUSIONS

The prevalence of dyspepsia (13.8%) and of IBS (5.8%) in a general Dutch adult population appears to be lower than are reported in other countries. Use of alcohol and coffee was not associated with functional bowel symptoms. Former and current smoking were strongly related to dyspepsia.

Effect of coffee on motor and sensory function of proximal stomach

Some people attribute dyspeptic symptoms to drinking coffee, suggesting that coffee affects one or more functions of the proximal gastrointestinal tract. In a randomized controlled, cross-over, single-blinded study, the effects of coffee on gastric relaxation, gastric wall compliance and sensations, elicited by distension, were investigated in 10 healthy volunteers. Using the barostat technique, volume changes of an intragastric bag were recorded for 20 min after intragastric administration of 280 ml of coffee or water. Then, after deflation, the volume of the bag was increased stepwise every 3 min to assess gastric wall compliance and wall tension. At the end of every volume step, sensations (nausea, pain, and bloating) were scored. During the first 20 min after coffee administration, the volume change of the intragastric bag was larger than after water (P < 0.05). There were no differences in gastric wall compliance, wall tension, or symptom scores. In conclusions, coffee, in comparison with water, enhances the adaptive relaxation of the proximal stomach, but has no effect on its wall compliance, wall tension, or sensory function.

The effect of coffee on gastric emptying and oro-caecal transit time

BACKGROUND

The consumption of coffee allegedly induces or aggravates gastrointestinal symptoms. In order to investigate the effect of coffee on gastrointestinal motility we studied the effect of coffee on gastric emptying and oro-caecal transit time.

METHODS

In a randomised, controlled, cross-over study gastric emptying and oro-caecal transit time were studied in 12 healthy volunteers, using applied potential tomography and lactulose hydrogen breath test, respectively. After 1 day of coffee abstinence and an overnight fast, coffee or the control drink (water) was drunk and 10 min thereafter a liquid nutrient meal was ingested together with lactulose. During 150 min, recordings were made with applied potential tomography and breath samples were taken every 5 min. Lag-phase duration and gastric half-emptying time were determined by two blinded observers.

RESULTS

The lag-phase duration after coffee (median 19.8 min, range 6-47 min) was not significantly different from that after water (median 19.3 min, range 11-37.5), nor was the gastric half-emptying time (median 75.7 min, range 56-157.6 vs. median 83.4 min, range 64. 6-148.4). Likewise, coffee had no significant effect on oro-caecal transit time (median 135 min, range 60-270 vs. median 140 min, range 55-270). No significant correlation between any of these parameters and mean daily coffee intake was found.

CONCLUSIONS

Coffee does not affect gastric emptying of a liquid meal or small bowel transit.

Effect of coffee on gastro-oesophageal reflux in patients with reflux disease and healthy controls

BACKGROUND

Many patients with gastro-oesophageal reflux disease (GORD) report that coffee aggravates their symptoms and doctors tend to discourage its use in GORD.

OBJECTIVE

To assess the effect of coffee ingestion on gastro-oesophageal acid reflux.

DESIGN

A randomized, controlled, crossover study.

PARTICIPANTS

Seven GORD patients and eight healthy subjects.

METHODS

After 1 day of coffee abstinence, participants underwent 24-h oesophageal pH and manometric monitoring. At well-defined times, they ingested either 280 ml of regular paper-filtered coffee or 280 ml of warm water. Coffee or water was drunk 1 h after breakfast, during lunch, 1 h after dinner and after an overnight fast Reflux and oesophageal motility parameters were assessed for the first hour after each coffee or water intake.

RESULTS

Coffee had no effect on postprandial acid reflux time or number of reflux episodes, either in GORD patients or in healthy subjects. Coffee increased the percentage acid reflux time only when ingested in the fasting period in the GORD patients (median 2.6, range 0-19.3 versus median 0, range 0-8.3; P = 0.028), but not in the healthy subjects. No effect of coffee on postprandial lower oesophageal sphincter pressure (LOSP), patterns of LOSP associated with reflux episodes or oesophageal contractions was found.

CONCLUSION

Coffee has no important effect on gastro-oesophageal acid reflux in GORD patients, and no effect at all in healthy subjects.

Coffee and gastrointestinal function: facts and fiction. A review

BACKGROUND

Effects of coffee on the gastrointestinal system have been suggested by patients and the lay press, while doctors tend to discourage its consumption in some diseases.

METHODS

The literature on the effects of coffee and caffeine on the gastrointestinal system is reviewed with emphasis on gastrointestinal function.

RESULTS

Although often mentioned as a cause of dyspeptic symptoms, no association between coffee and dyspepsia is found. Heartburn is the most frequently reported symptom after coffee drinking. It is demonstrated that coffee promotes gastro-oesophageal reflux. Coffee stimulates gastrin release and gastric acid secretion, but studies on the effect on lower oesophageal sphincter pressure yield conflicting results. Coffee also prolongs the adaptive relaxation of the proximal stomach, suggesting that it might slow gastric emptying. However, other studies indicate that coffee does not affect gastric emptying or small bowel transit. Coffee induces cholecystokinin release and gallbladder contraction, which may explain why patients with symptomatic gallstones often avoid drinking coffee. Coffee increases rectosigmoid motor activity within 4 min after ingestion in some people. Its effects on the colon are found to be comparable to those of a 1000 kCal meal. Since coffee contains no calories, and its effects on the gastrointestinal tract cannot be ascribed to its volume load, acidity or osmolality, it must have pharmacological effects. Caffeine cannot solely account for these gastrointestinal effects.

CONCLUSIONS

Coffee promotes gastro-oesophageal reflux, but is not associated with dyspepsia. Coffee stimulates gallbladder contraction and colonic motor activity.

After a decade of Helicobacter pylori in The Netherlands. A survey of the practice of the members of the Dutch Society of Gastroenterology

BACKGROUND

Knowledge of Helicobacter pylori infection has grown rapidly during the last decade and management of its associated pathology has changed concordantly.

METHODS

We surveyed the management of H. pylori infection among members of the Dutch Society of Gastroenterology in 1995 via a postal questionnaire.

RESULTS

Almost all 226 respondents (response rate 54%) treated patients for H. pylori infection and the responses suggested that at least 0.1% of Dutch citizens were treated for H. pylori infection in 1995 by this group of specialists. 98% of the respondents treated the H. pylori infection in patients with duodenal ulcer, 91% in cases of gastric ulcer, 56% in cases of gastric lymphoma, 33% in cases of premalignant changes in gastric mucosal histology, 32% in cases of non-ulcer dyspepsia, and 30% in cases of chronic use of proton pump inhibitors. The main diagnostic methods used were histology (93%), urease test (60%), and culture (46%). Triple therapy was most commonly used (54%), followed by quadruple therapy (26%) and double therapy (13%). Follow-up detection of H. pylori was routinely done by 42% of the respondents, while 48% did so only when confirmation of eradication was considered clinically relevant. Most specialists did follow-up detection after 8-12 weeks.

CONCLUSIONS

In 1995 most Dutch specialists treated H. pylori in patients with associated ulcer disease. There was no consensus on its role in other diseases. Diagnostic methods and treatment regimens for eradication differed widely.