Abstract

A 34-year-old male with a long history of immune thrombocytopenic purpura (ITP) presents to your office. His platelet count is 30 × 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.

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.

Table 1.

Proportion of Helicobacter pylori (HP)-positive and HP-negative adult patients with ITP achieving a platelet count response.

 HP-positive responders HP-positive non- responders HP-negative responders HP-negative non- responders Definition of response Country of origin 
Morimoto 20072  12 Platelet count increase by 20 or more above baseline Japan 
Asahi 20063  16 26 11 Increase in platelet count by 100 or more by 24 weeks Japan 
Inaba 20054  11 25 10 Platelet count above 100 Japan 
Takahashi 20045  15 Platelet count increase by 20 or more above baseline Japan 
Michel 20046  15 10 Platelet count at least 50 and double from baseline USA 
Ando 20047  10 17 Platelet count above 90 Japan 
Hino 20038  12 21 Significant increase in platelet count Japan 
Overall response 65 (49.6%) 131 44   
 HP-positive responders HP-positive non- responders HP-negative responders HP-negative non- responders Definition of response Country of origin 
Morimoto 20072  12 Platelet count increase by 20 or more above baseline Japan 
Asahi 20063  16 26 11 Increase in platelet count by 100 or more by 24 weeks Japan 
Inaba 20054  11 25 10 Platelet count above 100 Japan 
Takahashi 20045  15 Platelet count increase by 20 or more above baseline Japan 
Michel 20046  15 10 Platelet count at least 50 and double from baseline USA 
Ando 20047  10 17 Platelet count above 90 Japan 
Hino 20038  12 21 Significant increase in platelet count Japan 
Overall response 65 (49.6%) 131 44   

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

References
1
Franchini M, Cruciani M, Mengoli C, Pizzolo G, Veneri D. Effect of Helicobacter pylori eradication on platelet count in idiopathic thrombocytopenic purpura: a systematic review and meta-analysis.
J Antimicrob Chemother
.
2007
;
60
:
237
–246.
2
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.
3
Asahi A, Kuwana M, Suzuki H et al. Effects of a Helicobacter pylori eradication regimen on anti-platelet autoantibody response in infected and uninfected patients with idiopathic thrombocytopenic purpura.
Haematologica
.
2006
;
91
:
1436
–1437.
4
Inaba T, Mizuno M, Take S, et al. Eradication of Helicobacter pylori increases platelet count in patients with idiopathic thrombocytopenic purpura in Japan.
Eur J Clin Invest
.
2005
;
35
:
214
–219.
5
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.
6
Michel M, Cooper N, Jean C, Frissora C, Bussel JB. Does Helicobater pylori initiate or perpetuate immune thrombocytopenic purpura?
Blood
.
2004
;
103
:
890
–896.
7
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.
8
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.

Author notes

1

Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada

2

Department of Medical Sciences, Ospedale Regina Apostolorum, Albano laziaile, Italy