Hematology 2008
Does Helicobacter pylori Eradication Therapy Result in a Platelet Count Improvement in Adults with Immune Thrombocytopenic Purpura Regardless of H pylori Infection?
ASH Evidence-based Review 2008
Donald M. Arnold1 and
Roberto Stasi2
Correspondence: Donald M. Arnold, 1200 Main Street West, Room 3V-48, Hamilton, Ontario, Canada, L8N 3Z5; Phone 905-521-2100 ext 786305; Fax 905-521-4971; e-mail arnold{at}mcmaster.ca
Abstract
A 34-year-old male with a long history of immune thrombocytopenic purpura (ITP) presents to your office. His platelet count is 30 x 109/L and he is clinically stable with no bleeding symptoms. He has read that Helicobacter pylori eradication therapy may be effective for ITP and he asks you about this. You do not have access to reliable tests for H pylori infection (e.g., urea breath test), yet you wonder about the benefit of empiric eradication therapy for your patient.
A causal relationship between H pylori infection and ITP has been suggested by studies showing platelet count improvements following H pylori eradication in infected patients. However, alternate explanations for a platelet count response following treatment are possible including the eradication of bacteria other than H pylori or immune modulating effects of the treatment itself. Moreover, a recent meta-analysis demonstrated that patients receiving treatment had a greater increase in platelet count from baseline compared with untreated controls regardless of the outcome of eradication therapy.1 To examine the independent effect of H pylori treatment on improvement of thrombocytopenia, we performed a comprehensive literature review of all studies evaluating the platelet count response to H pylori treatment in infected and uninfected adults with ITP.
A literature search was performed by combining the MESH term "purpura, thrombocytopenic, idiopathic" and the keywords "idiopathic thrombocytopenic purpura" and "immune thrombocytopenic purpura" (no restrictions, 3116 hits), and the MESH term "Helicobacter pylori" (no restrictions, 21871 hits), and the MESH terms "randomized controlled trial as topic," "randomized controlled trial," and "prospective studies" (no restrictions, 306471 hits) between 1950 and April 2008. This strategy yielded 85 citations including one meta-analysis, from which 10 additional references were taken from the bibliography. Excluded were 44 non-adult citations, 16 case reports, 8 reviews and 1 reference about non–H pylori infection, leaving 26 citations. Of those, 19 reports preselected H pylori–positive patients only and were excluded, leaving 7 eligible studies (n = 222). A platelet count response was achieved following H pylori therapy in 65 (49.6%) of 131 infected patients, and none of the 44 uninfected patients (Table 1
)—differing definitions of "success" limit the strength of this conclusion, and most studies were from Japan, where the prevalence of H pylori infection is high.
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Table 1. Proportion of Helicobacter pylori (HP)-positive and HP-negative adult patients with ITP achieving a platelet count response.
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We conclude, based on this review, that treatment of thrombocytopenia in adults with ITP using H pylori eradication therapy should be reserved for patients with active H pylori infection (Grade 2C). A beneficial effect of the treatment itself was not observed.
Footnotes
1 Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada 
2 Department of Medical Sciences, Ospedale Regina Apostolorum, Albano laziaile, Italy
Disclosures
Conflict-of-interest disclosure: D.M.A. receives research funding from Hoffman LaRoche. R.S. declares no competing financial interests.
Off-label drug use: None disclosed.
References
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- Morimoto N, Takeuchi H, Takahashi T, et al. Helicobacter pylori-associated chronic idiopathic thrombocytopenic purpura and low molecular weight H. pylori proteins. Scand J Infect Dis. 2007;39:409–416.[CrossRef][Medline]
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- Takahashi T, Yujiri T, Shinohara K, et al. Molecular mimicry by Helicobacter pylori CagA protein may be involved in the pathogenesis of H. pylori-associated chronic idiopathic thrombocytopenic purpura. Br J Haematol. 2004;124:91–96.[CrossRef][Medline]
- Michel M, Cooper N, Jean C, Frissora C, Bussel JB. Does Helicobater pylori initiate or perpetuate immune thrombocytopenic purpura? Blood. 2004;103:890–896.[Abstract/Free Full Text]
- Ando T, Tsuzuki T, Mizuno T, et al. Characteristics of Helicobacter pylori-induced gastritis and the effect of H. pylori eradication in patients with chronic idiopathic thrombocytopenic purpura. Helicobacter. 2004;9:443–452.[CrossRef][Medline]
- Hino M, Yamane T, Park K, et al. Platelet recovery after eradication of Helicobacter pylori in patients with idiopathic thrombocytopenic purpura. Ann Hematol. 2003;82:30–32.[Medline]
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