Peptic ulcer medical therapy

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2017 ACG Guidelines for Peptic Ulcer Disease
Guidelines for the Indications to Test for, and to Treat, H. pylori Infection
Guidelines for First line Treatment Strategies of Peptic Ulcer Disease for Providers in North America
Guidlines for factors that predict the successful eradication when treating H. pylori infection
Guidelines to document H. pylori antimicrobial resistance in the North America
Guidelines for evaluation and testing of H. pylori antibiotic resistance
Guidelines for when to test for treatment success after H. pylori eradication therapy
Guidelines for penicillin allergy in patients with H. pylori infection
Guidelines for the salvage therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Guillermo Rodriguez Nava, M.D. [2]

Overview

• Younger patients with ulcer-like symptoms are often treated with antacids or H2 antagonists before EGD is undertaken.Bismuth compounds may actually reduce or even clear organisms.

• Patients who are taking nonsteroidal anti-inflammatories (NSAIDs) may also be prescribed a prostaglandin analogue (Misoprostol) in order to help prevent peptic ulcers, which may be a side-effect of the NSAIDs.

• When H. pylori infection is present, the most effective treatments are combinations of 2 antibiotics (e.g. Erythromycin,Ampicillin, Amoxicillin, Tetracycline, Metronidazole) and 1 proton pump inhibitor (PPI). An effective combination would be Amoxicillin + Metronidazole + Pantoprazole (a PPI). In the absence of H. pylori, long-term higher dose PPIs are often used.

• Treatment of H. pylori usually leads to clearing of infection, relief of symptoms and eventual healing of ulcers. Recurrence of infection can occur and retreatment may be required, if necessary with other antibiotics. Since the widespread use of PPI's in the 1990s, surgical procedures (like "highly selective vagotomy") for uncomplicated peptic ulcers became obsolete.

Contraindicated medications

Bleeding peptic ulcer is considered an absolute contraindication to the use of the following medications:

• Ketorolac tromethamine
• Ticlopidine
• Prasugrel
• Reserpine
• Streptokinase
• Vorapaxar

Principles of Eradication Therapy for Helicobacter pylori infection

The following table contains the indications for diagnosis and treatment of Helicobacter pylori infection

Indications for diagnosis and treatment of Helicobacter pylori infection
Active peptic ulcer disease
Confirmed history of peptic ulcer disease not previously treated for H. pylori
Gastric MALT lymphoma
After endoscopic resection of early gastric cancer

• Low clarithromycin resistance areas (<15%):
  • In areas of low resistance the PPI-clarithromycin-containing triple therapy is recommended as the first-line treatment as well as bismuth-containing quadruple therapy.
  • In areas of low resistance after failure of a PPI-clarithromycin-containing treatment, either a bismuth-containing quadruple therapy or levofloxacin-containing triple therapy is recommended.
• High clarithromycin resistance areas (≥15%):
  • In areas of high resistance, bismuth-containing quadruple therapy is recommended as the first-line treatment.
  • In areas of high resistance after failure of bismuth containing quadruple therapy, Levofloxacin containing triple therapy is recommended.
• If the second-line treatment fails, the antibiotic therapy should guided by antimicrobial susceptibility testing.
• FDA approved first line regimens duration:
  • Triple therapy: 7 days (10 days if rabeprazole is used).
  • Quadruple therapy: 4 weeks.
• Patients who have had a previous H. pylori associated ulcer or gastric MALT lymphoma or who have had surgical resection for early gastric cancer, confirmation tests for eradication of H. pylori infection should be done.
• The best nonendoscopic test to confirm eradication of H. pylori infection is the urea breathing test.
• Testing to prove H. pylori eradication is most accurate if performed 4 weeks after the completion of the therapy.

Countries with a reported prevalence <15% of H. pylori resistance to clarithromycin

Europe	North America	South America	Middle East	Far East
Belgium (3%) Croatia (8.2%) Denmark (11%) Finland (2%) Germany (2.2–4%) Italy (North) (1.8%) Ireland (8.8%) Netherlands (1.7%) Sweden (2.9%) UK (8.3–12.7%)	Canada (12%) USA (10.6–12.2%)†	Brazil (9.8%)	Israel (8.2%) Saudi Arabia (4%)	Bangladesh (10%) Hong Kong (4.5%) Korea (14%) Malaysia (2.1% New Zealand (11%)

^† There is a reported prevalence of 15% in the Northeast of the US.

Countries with a reported prevalence ≥15% of H. pylori resistance to clarithromycin

Europe	North America	Middle East	Far East
Bulgaria (18.4%) France (20%) Italy (central) (23.4%) Portugal (22%) Spain (49.2%) Turkey (48.2%)	Mexico (25%)	Iran (17%)	China (18%) India (33%) Japan (27.7%) Taiwan (13.5)

Helicobacter pylori Eradication Therapies

▸ Click on the following categories to expand treatment regimens.

First line   ▸  Triple therapy   ▸  Quadruple therapy Second line   ▸  Triple therapy   ▸  Sequential therapy   ▸  Hybrid therapy Third line therapy (Rescue therapy)   ▸  Rifabutin based

Triple therapy ▸ Lansoprazole 30 mg q12h OR ▸ Omeprazole 20 mg q12h OR ▸ Esomeprazole 40 mg q24h OR ▸ Rabeprazole 20 mg q12h PLUS ▸ Clarithromycin 500 mg q12h. PLUS ▸ Amoxicillin 1 g q12h Quadruple therapy ▸ Bismuth subsalicylate 525 mg orally q6h PLUS ▸ Metronidazole 250 mg orally q6h PLUS ▸ Tetracycline 500 mg orally q6h PLUS ▸ Ranitidine 150 mg orally q12h OR ▸ Lansoprazole 30 mg q12h OR ▸ Omeprazole 20 mg q12h OR ▸ Esomeprazole 40 mg q24h OR ▸ Rabeprazole 20 mg q12h Triple therapy ▸ Lansoprazole 30 mg q12h OR ▸ Omeprazole 20 mg q12h OR ▸ Esomeprazole 40 mg q24h OR ▸ Rabeprazole 20 mg q12h PLUS ▸ Clarithromycin 500 mg q12h PLUS ▸ Metronidazole 500 mg q12h Sequential therapy First 5 days ▸ Lansoprazole 30 mg q12h OR ▸ Omeprazole 20 mg q12h OR ▸ Esomeprazole 40 mg q24h OR ▸ Rabeprazole 20 mg q12h PLUS ▸ Amoxicillin 1 g q12h Next 5 days ▸ Lansoprazole 30 mg q12h OR ▸ Omeprazole 20 mg q12h OR ▸ Esomeprazole 40 mg q24h OR ▸ Rabeprazole 20 mg q12h PLUS ▸ Clarithromycin 500 mg q12h PLUS ▸ Tinidazole 500 mg q12h Sequential therapy First 7 days ▸ Lansoprazole 30 mg q12h OR ▸ Omeprazole 20 mg q12h OR ▸ Esomeprazole 40 mg q24h OR ▸ Rabeprazole 20 mg q12h PLUS ▸ Amoxicillin 1 g q12h Next 7 days ▸ PPI standard dose PLUS ▸ Amoxicillin 1 g q12h PLUS ▸ Clarithromycin 500 mg q12h PLUS ▸ Metronidazole 500 mg q12h Third line treatment ▸ Rifabutin 150 mg q2h PLUS ▸ Amoxicillin 1 g IV q12h PLUS ▸ Ciprofloxacin 500 mg/kg IV q12h

References

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