Sandbox MKK

The ACG’s 2007 treatment guideline on the management of H. pylori infection (26) listed the following as established indications for diagnosis and treatment:

Indications

• Active PUD (gastric or duodenal).
• Confirmed history of PUD (not previously treated for H. pylori)
• Gastric MALT lymphoma (low grade)
• After endoscopic resection of EGC

Recommended first-line treatment for Helicobacter pylori

Regimen	Drug dose	Dosing frequency	Duration(days)	FDA approval
Clarithromycin triple	PPI(standard or double dose Clarithromycin(500mg) Amoxicillin(1gm)or Metronidazole(500mg TID)	BID	14 days	YES†
Bismuth Quadruple	PPI(standard dose) Bismuth subcitrate (120-300mg)or Subsalicylate (300mg) Tetracyclin(500mg) Metronidazole(250-500mg)	BID QID QID TID to QID (500mg)	10-14 days	NO‡
Concomitant	PPI (standard dose) Clarithromycin (500mg) Amoxicillin(1gm) Nitroimidazole(500mg)	BID	10 -14 days	NO
Sequential	PPI(standard dose)+Amoxicillin(1gm) PPI,Clarithromycin(500mg)+Nitroimidazole(500mg)	BID BID	5-7 days 5-7 days	NO
Hybrid	PPI(standard)+Amoxicillin(1gm) PPI,Amoxicillin,Clarithromycin(500mg),Nitroimidazole(500mg)	BID BID	7 days 7 days	NO
Levofloxacin triple	PPI(standard dose) Levofloxacin(500mg) Amoxicillin(1gm)	BID QID BID	10-14 days	NO
Levofloxacin sequential	PPI(standard or double dose)+Amoxicillin(1 gm) PPI,Amoxicillin,Levofloxacin(500mg QD),Nitroimidazole(500mg)	BID BID	5-7 days	NO
LOAD	Levofloxacin(250mg) PPI(double dose) Nitazoxanide(500mg) Doxycycline(100mg)	QD QD BID QD	7-10 days	NO

†: Several PPI, Clarithromycin, and Amoxicillin combinations have achieved FDA approval ,PPI, Clarithromycin, Metronidazole is not an FDA approved treatment regimen.

‡: PPI, Bismuth, Tetracycline and metronidazole prescribed separately is not an FDA approved treatment regimen.However ,Pylera, a combination product containing Bismuth subcitrate,Tetracycline , Metronidazole combination with PPi for 10 days is an FDA approved regimen.

Adjuvant therapy in the treatment of H. pylori infection:

Emerging evidence suggests an inhibitory effect of Lactobacillus and Bifidobacterium species on H. pylori. Furthermore, these probiotic strains may also help to reduce the side effects of eradication therapies and improve compliance with therapy.

Selection of firstline Treatment

•Is there a penicillin (PCN) allergy? •Previous macrolide (MCL) exposure for any reason ?

•PCN allergy: No •MCL exposure: No

•PCN allergy: No •MCL exposure: Yes

•PCN allergy: Yes •MCL exposure: No

•PCN allergy: Yes •MCL exposure: Yes

Recomended treatment: •Bismuth quadruple •Clarithromycin triple with amoxicillin Other options: •Sequential •HYBRID •Levofloxacin triple •Levofloxacin sequential •LOAD

Recomended treatment: •Bismuth quadruple •Levofloxacin sequential Other options: •Concomitant therapy •Sequential therapy • HYBRID •LOAD

Recomended treatment: •Bismuth quadruple •Clarithromycin triple with metronidazole •Bismuth quadruple

Recomended treatment: •Bismuth quadruple •Clarithromycin triple with metronidazole •Bismuth quadruple

Persistent Helicobacter pylori infection

Patient recieved clarithromycin triple therapy

Patient received Bismuth quadriple therapy

•No previous Quinolone exposure •No PCN allergy Recomended treatment: •Bismuth quadruple •Levofloxacin •Rifabutin triple •High dose dual

•Previous Quinolone exposure •No PCN Allergy Recomended treatment: •Bismuth quadruple therapy •Rifabutin triple •High dose dual

•No previous Quinolone exposure •PCN Allergy Recomended treatment: •Bismuth quadruple

•Previous Quinolone exposure •PCN Allergy Recomended treatment: •Bismuth quadruple

•No previous Quinolone exposure •No PCN allergy Recomended treatment: •Levofloxacin triple concomitant •Rifabutin triple •High dose triple

•Previous Quinolone exposure •No PCN Allergy Recomended treatment: •Concomitant Rifabutin triple •High dose dual

•No previous Quinolone exposure •PCN Allergy Recomended treatment: •PPI,Clarithromycin ,Metronidazole •PPI,Levofloxacin, Metronidazole

•Previous Quinolone exposure •No PCN Allergy Recomended treatment: •PPI,Clarithromycin, Metronidazole •Bismuth quadruple

Diagnostic testing

The American Journal of Gastroenterology guidelines recommend that endoscopy should be performed to rule out peptic ulcer disease, esophagogastric malignancy, and other rare upper gastrointestinal tract disease in the following settings:

• Dyspeptic patients more than 55 years old
  OR
• Dyspeptic patients with alarm features

• Bleeding
• Anemia
• Early satiety
• Unexplained weight loss (> 10% body weight)
• Progressive dysphagia
• Odynophagia
• Persistent vomiting
• A family history of gastrointestinal cancer
• Previous esophagogastric malignancy
• Previous documented peptic ulcer, lymphadenopathy, or an abdominal mass

In patients aged 55 years or younger with no alarm features, two management options may be considered:

• Test-and-treat strategy using a validated noninvasive test (urea breathing test or stool antigen test) for H. pylori and a trial of acid suppression if eradication is successful but symptoms do not resolve – preferable in populations with a moderate to high prevalence of H. pylori infection (≥ 10%)
• Empiric trial of acid suppression with a proton pump inhibitor for 4–8 weeks – preferable in low prevalence situations

Repeat endoscopy is not recommended once a firm diagnosis of functional dyspepsia has been established, unless new symptoms or alarm features develop. Testing to prove H. pylori eradication is most accurate if performed 4 weeks after the completion of therapy.