What is Evidence-Based Medicine for Helicobacter Pylori?

Full article (Clin Gastroenterol Hepatol 2014; 12: 177-86): http://ow.ly/sPKbi 

My take on the most important parts of this Helicobacter pylori (HP) article:

  • Success defined: curing HP ≥95% =excellent, curing HP ≥90% =good, acceptable ≥85%, and unsatisfactory <85%.
  • “Because clarithromycin-containing triple therapy and 10-day sequential therapy are now only effective in special populations, they are considered obsolete.”
  • The “preferred choices for Western countries” are the following
  1. 14-day concomitant therapy: PPI, amoxicillin 1 g, clarithromycin 500 mg, metronidazole -all twice daily
  2. 14-day bismuth quadruple therapy: PPI BID, bismuth BID, tetracycline 500 mg QID, metronidazole 500 mg TID
  3. 14-day hybrid sequential-concomitant therapy: 7 days of PPI-amoxicillin 1 g, followed by amoxicillin 1 g, clarithromycin 500 mg, metronidazole 500 mg for 7 days-all BID

Other useful points:

  • Tetracycline is not available in many parts of the world and generally doxycycline is not an adequate substitute for tetracycline.
  • Triple therapies are extremely sensitive to resistance of the third drug (eg. clarithromycin and metronidazole).  The increase in resistance is making these regimens ineffective
  • An online calculator can help predict which therapy to choose: https://hp-therapy.biomed.org/tw/ (need to know local resistance)
  • Poor compliance is the other factor besides resistance that can undermine a well-constructed treatment regimen. Spending ample time educating patients about the need to  take all of their medicines is crucial.
  • Figure 1 on page 178 outlines the recommended treatment approach.  Unfortunately, availability of susceptibility testing has been quite limited.

Take-home message: The authors emphasize using regimens that work locally and using the evidence that we have to choose the best treatments.  However, given the resistance patterns, working on collaborating with laboratories to culture HP for susceptibility/resistance would be worthwhile to increase the likelihood of excellent outcomes.

Related blog links:

Also noted:  full text article online (from Kipp Ellsworth twitter feed): http://goo.gl/dD2ooF “Intestinal Transplantation: An Unexpected Journey”  This is a succinct overview of intestinal transplantation’s progress and potential.

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Helicobacter pylori –useful advice

Helicobacter pylori (H pylori) infections remain an important cause of gastritis, ulcers, and adenocarcinoma of the stomach.  One new approach in treatment has been the use of sequential therapy.  More data is now available on the effectiveness of this approach and choice of antibiotics (Gastroenterology 2012; 143: 55-61 & editorial 10-12).

In the study, a 10-day sequential regimen (SR) was compared with a 5-day concomitant regimen (CR).

  • CR group (n=90): esomeprazole 40 mg BID, amoxicillin 1 g BID, levofloxacin 500 mg BID, tinidazole 500 mg BID.  Eradication rate (intention-to-treat): 92%
  • SR group (n-90): esomeprazole 40 mg BID, amoxicillin 1 g BID for 5 days, then esomeprazole 40 mg BID, levofloxacin 500 mg BID, tinidazole 500 mg BID for 5 days. Eradication rate (intention-to-treat): 93%
  • Both groups had good results in part due to low resistance rates

Useful advice on this study from the editorial:

  • ‘We prefer concomitant therapy because it is not complex and it may retain its effectiveness at a slightly higher level of resistance compared with sequential therapy.”  Authors prefer 4-drug non-bismuth-containing concomitant treatment.
  • With bismuth therapy (eg. bismuth-metronidazole-tetracycline-PPI), authors prefer a 14 day course.  10-day treatment may be effective when metronidazole resistance is considered unlikely.
  • “Clarithromycin should be abandoned as an empiric regimen” due to resistance in U.S.
  • Fluoroquinolone resistance is increasing rapidly and “prior use virtually ensures resistance.”  Suggested use of fluoroquinolone therapy among adults would be as a rescue therapy (failed 2 different therapies), using dosing regimen as noted in cited study, and in patient without history of prior fluoroquinolone use (&/or proof on susceptibility testing)
What about treatment in kids?
In pediatrics, guidelines for treatment have been recently updated (JPGN 2011; 53: 230-43). (Benjamin Gold, MD -one of my partners is one of the authors and was the lead author of the first guidelines published in 2000.)  NASPGHAN guidelines. PDF of powerpoint slides: H. pylori infection in children: ESPGHAN/ NASPGHAN guidelines … & pdf of text: Evidence-based guidelines from ESPGHAN and NASPGHAN for …
Recommendations for first line treatment are a triple-based therapy with PPI and two antibiotics (eg. amoxicillin and metronidazole).  Alternatives, include bismuth plus two antibiotics, or sequential therapy.  Use of clarithromycin is recommended only after susceptibility testing.

Additional references:

  • -Gut 2010; 59: 1143-53.  Changing treatment recommendations for Helicobacter pylori in the face of resistance.
  • -Am J Gastroenterol 2007;  102: 1808-1825. American College of Gastroenterology Guideline on the Management of Helicobacter pylori Infection.  Doxycycline can be used in place of tetracycline
  • -Gastroenterol 2007; 133: 985. Review. Good article for resistant infections.
  • -Gastroenterol 2005; 129:1414-19.  Sequential Rx (amox + PPI x 5 days, then biaxin, tinidazole, PPI for 5 days) had 97% success.