Peptic ulcer medical therapy: Difference between revisions

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{{Peptic ulcer}}
{{Peptic ulcer}}{{CMG}}
{{CMG}}; {{AE}} {{GRN}}
==Medical Therapy==
==Overview==
* Younger patients with ulcer-like symptoms are often treated with [[antacid]]s or [[H2 antagonist]]s before EGD is undertaken.[[Bismuth subsalicylate|Bismuth compounds]] may actually reduce or even clear organisms.
* Younger patients with ulcer-like symptoms are often treated with [[antacid]]s or [[H2 antagonist]]s before EGD is undertaken.[[Bismuth subsalicylate|Bismuth compounds]] may actually reduce or even clear organisms.


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* 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.
* 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.
==Principles of Eradication Therapy for ''Helicobacter pylori'' infection==
#Indications for diagnosis and treatment, established:<ref name="pmid17608775">{{cite journal| author=Chey WD, Wong BC, Practice Parameters Committee of the American College of Gastroenterology| title=American College of Gastroenterology guideline on the management of Helicobacter pylori infection. | journal=Am J Gastroenterol | year= 2007 | volume= 102 | issue= 8 | pages= 1808-25 | pmid=17608775 | doi=10.1111/j.1572-0241.2007.01393.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17608775  }} </ref>
## 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.
## Uninvestigated dyspepsia (review ''H. pylori'' prevalence).
#'''Low''' clarithromycin '''resistance''' areas '''(<15%)''':<ref name="pmid22491499">{{cite journal| author=Malfertheiner P, Megraud F, O'Morain CA, Atherton J, Axon AT, Bazzoli F et al.| title=Management of Helicobacter pylori infection--the Maastricht IV/ Florence Consensus Report. | journal=Gut | year= 2012 | volume= 61 | issue= 5 | pages= 646-64 | pmid=22491499 | doi=10.1136/gutjnl-2012-302084 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22491499  }} </ref>
##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%)''':<ref name="pmid22491499">{{cite journal| author=Malfertheiner P, Megraud F, O'Morain CA, Atherton J, Axon AT, Bazzoli F et al.| title=Management of Helicobacter pylori infection--the Maastricht IV/ Florence Consensus Report. | journal=Gut | year= 2012 | volume= 61 | issue= 5 | pages= 646-64 | pmid=22491499 | doi=10.1136/gutjnl-2012-302084 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22491499  }} </ref>
##In areas of '''high resistance''', '''bismuth-containing quadruple therapy''' are recommended for first-line treatment.
##In areas of '''high resistance''' after '''failure of bismuth containing quadruple therapy''', '''levofloxacin containing triple therapy''' is recommended.
#After '''failure of second-line treatment''', treatment should be guided by '''antimicrobial susceptibility''' testing.<ref name="pmid22491499">{{cite journal| author=Malfertheiner P, Megraud F, O'Morain CA, Atherton J, Axon AT, Bazzoli F et al.| title=Management of Helicobacter pylori infection--the Maastricht IV/ Florence Consensus Report. | journal=Gut | year= 2012 | volume= 61 | issue= 5 | pages= 646-64 | pmid=22491499 | doi=10.1136/gutjnl-2012-302084 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22491499  }} </ref>
#FDA approved first line regimens duration:<ref name="pmid17608775">{{cite journal| author=Chey WD, Wong BC, Practice Parameters Committee of the American College of Gastroenterology| title=American College of Gastroenterology guideline on the management of Helicobacter pylori infection. | journal=Am J Gastroenterol | year= 2007 | volume= 102 | issue= 8 | pages= 1808-25 | pmid=17608775 | doi=10.1111/j.1572-0241.2007.01393.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17608775  }} </ref>
##Triple therapy: 7 days (10 days if [[rabeprazole]]).
##Quadruple therapy: 4 weeks.
#Confirm the eradication of ''H. pylori'' infection in patients who have had an ''H. pylori''-associated ulcer or gastric MALT lymphoma or who have undergone resection for early gastric cancer.<ref name="pmid20427808">{{cite journal| author=McColl KE| title=Clinical practice. Helicobacter pylori infection. | journal=N Engl J Med | year= 2010 | volume= 362 | issue= 17 | pages= 1597-604 | pmid=20427808 | doi=10.1056/NEJMcp1001110 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20427808  }} </ref>
#The urea breathing test is the most reliable nonendoscopic test to document eradication of ''H. pylori'' infection.<ref name="pmid17608775">{{cite journal| author=Chey WD, Wong BC, Practice Parameters Committee of the American College of Gastroenterology| title=American College of Gastroenterology guideline on the management of Helicobacter pylori infection. | journal=Am J Gastroenterol | year= 2007 | volume= 102 | issue= 8 | pages= 1808-25 | pmid=17608775 | doi=10.1111/j.1572-0241.2007.01393.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17608775  }} </ref>
#Testing to prove ''H. pylori'' eradication is most accurate if performed at 4 weeks after the completion of eradication therapy.<ref name="pmid20427808">{{cite journal| author=McColl KE| title=Clinical practice. Helicobacter pylori infection. | journal=N Engl J Med | year= 2010 | volume= 362 | issue= 17 | pages= 1597-604 | pmid=20427808 | doi=10.1056/NEJMcp1001110 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20427808  }} </ref>
{| style="border: 2px solid #DCDCDC; font-size: 90%; width: 80%;"
|+ '''Countries with a reported prevalence <15% of ''H. pylori'' resistance to clarithromycin'''<ref name="pmid15306603">{{cite journal| author=Mégraud F| title=H pylori antibiotic resistance: prevalence, importance, and advances in testing. | journal=Gut | year= 2004 | volume= 53 | issue= 9 | pages= 1374-84 | pmid=15306603 | doi=10.1136/gut.2003.022111 | pmc=PMC1774187 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15306603  }} </ref><ref name="pmid15207062">{{cite journal| author=Duck WM, Sobel J, Pruckler JM, Song Q, Swerdlow D, Friedman C et al.| title=Antimicrobial resistance incidence and risk factors among Helicobacter pylori-infected persons, United States. | journal=Emerg Infect Dis | year= 2004 | volume= 10 | issue= 6 | pages= 1088-94 | pmid=15207062 | doi=10.3201/eid1006.030744 | pmc=PMC3323181 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15207062  }} </ref><ref name="pmid21188333">{{cite journal| author=De Francesco V, Giorgio F, Hassan C, Manes G, Vannella L, Panella C et al.| title=Worldwide H. pylori antibiotic resistance: a systematic review. | journal=J Gastrointestin Liver Dis | year= 2010 | volume= 19 | issue= 4 | pages= 409-14 | pmid=21188333 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21188333  }} </ref><ref name="pmid20014902">{{cite journal| author=Boyanova L, Mitov I| title=Geographic map and evolution of primary Helicobacter pylori resistance to antibacterial agents. | journal=Expert Rev Anti Infect Ther | year= 2010 | volume= 8 | issue= 1 | pages= 59-70 | pmid=20014902 | doi=10.1586/eri.09.113 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20014902  }} </ref>
! style="background: #DCDCDC;" | Europe
! style="background: #DCDCDC;" | North America
! style="background: #DCDCDC;" | South America
! style="background: #DCDCDC;" | Middle East
! style="background: #DCDCDC;" | Far East
|-
| style="background: #F5F5F5; padding: 0 10px; width: 20%;" valign=top |
* 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%)
| style="background: #F5F5F5; padding: 0 10px; width: 20%;" valign=top |
* Canada (12%)
* USA (10.6–12.2%)<sup>†</sup>
| style="background: #F5F5F5; padding: 0 10px; width: 20%;" valign=top |
* Brazil (9.8%)
| style="background: #F5F5F5; padding: 0 10px; width: 20%;" valign=top |
* Israel (8.2%)
* Saudi Arabia (4%)
| style="background: #F5F5F5; padding: 0 10px; width: 20%;" valign=top |
* Bangladesh (10%)
* Hong Kong (4.5%)
* Korea (14%)
* Malaysia (2.1%
* New Zealand (11%)
|}
<SMALL><sup>†</sup> There is a reported prevalence of 15% in the Northeast of the US.</SMALL>
{| style="border: 2px solid #DCDCDC; font-size: 90%; width: 66%;"
|+ '''Countries with a reported prevalence ≥15% of H. pylori resistance to clarithromycin'''<ref name="pmid15306603">{{cite journal| author=Mégraud F| title=H pylori antibiotic resistance: prevalence, importance, and advances in testing. | journal=Gut | year= 2004 | volume= 53 | issue= 9 | pages= 1374-84 | pmid=15306603 | doi=10.1136/gut.2003.022111 | pmc=PMC1774187 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15306603  }} </ref><ref name="pmid15207062">{{cite journal| author=Duck WM, Sobel J, Pruckler JM, Song Q, Swerdlow D, Friedman C et al.| title=Antimicrobial resistance incidence and risk factors among Helicobacter pylori-infected persons, United States. | journal=Emerg Infect Dis | year= 2004 | volume= 10 | issue= 6 | pages= 1088-94 | pmid=15207062 | doi=10.3201/eid1006.030744 | pmc=PMC3323181 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15207062  }} </ref><ref name="pmid21188333">{{cite journal| author=De Francesco V, Giorgio F, Hassan C, Manes G, Vannella L, Panella C et al.| title=Worldwide H. pylori antibiotic resistance: a systematic review. | journal=J Gastrointestin Liver Dis | year= 2010 | volume= 19 | issue= 4 | pages= 409-14 | pmid=21188333 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21188333  }} </ref><ref name="pmid20014902">{{cite journal| author=Boyanova L, Mitov I| title=Geographic map and evolution of primary Helicobacter pylori resistance to antibacterial agents. | journal=Expert Rev Anti Infect Ther | year= 2010 | volume= 8 | issue= 1 | pages= 59-70 | pmid=20014902 | doi=10.1586/eri.09.113 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20014902  }} </ref>
! style="background: #DCDCDC;" | Europe
! style="background: #DCDCDC;" | North America
! style="background: #DCDCDC;" | Middle East
! style="background: #DCDCDC;" | Far East
|-
| style="background: #F5F5F5; padding: 0 10px; width: 20%;" valign=top |
* Bulgaria (18.4%)
* France (20%)
* Italy (central) (23.4%)
* Portugal (22%)
* Spain (49.2%)
* Turkey (48.2%)
| style="background: #F5F5F5; padding: 0 10px; width: 20%;" valign=top |
* Mexico (25%)
| style="background: #F5F5F5; padding: 0 10px; width: 20%;" valign=top |
* Iran (17%)
| style="background: #F5F5F5; padding: 0 10px; width: 20%;" valign=top |
* China (18%)
* India (33%)
* Japan (27.7%)
* Taiwan (13.5)
|}
==''Helicobacter pylori'' Eradication Therapies==
<SMALL><font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font><ref name="pmid17608775">{{cite journal| author=Chey WD, Wong BC, Practice Parameters Committee of the American College of Gastroenterology| title=American College of Gastroenterology guideline on the management of Helicobacter pylori infection. | journal=Am J Gastroenterol | year= 2007 | volume= 102 | issue= 8 | pages= 1808-25 | pmid=17608775 | doi=10.1111/j.1572-0241.2007.01393.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17608775  }} </ref><ref name="pmid24587620">{{cite journal| author=Garza-González E, Perez-Perez GI, Maldonado-Garza HJ, Bosques-Padilla FJ| title=A review of Helicobacter pylori diagnosis, treatment, and methods to detect eradication. | journal=World J Gastroenterol | year= 2014 | volume= 20 | issue= 6 | pages= 1438-49 | pmid=24587620 | doi=10.3748/wjg.v20.i6.1438 | pmc=PMC3925853 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24587620  }} </ref><ref name="pmid24011247">{{cite journal| author=O'Connor A, Molina-Infante J, Gisbert JP, O'Morain C| title=Treatment of Helicobacter pylori infection 2013. | journal=Helicobacter | year= 2013 | volume= 18 Suppl 1 | issue=  | pages= 58-65 | pmid=24011247 | doi=10.1111/hel.12075 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24011247  }} </ref><ref name="pmid20427808">{{cite journal| author=McColl KE| title=Clinical practice. Helicobacter pylori infection. | journal=N Engl J Med | year= 2010 | volume= 362 | issue= 17 | pages= 1597-604 | pmid=20427808 | doi=10.1056/NEJMcp1001110 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20427808  }} </ref><ref name="pmid24587627">{{cite journal| author=Song M, Ang TL| title=Second and third line treatment options for Helicobacter pylori eradication. | journal=World J Gastroenterol | year= 2014 | volume= 20 | issue= 6 | pages= 1517-28 | pmid=24587627 | doi=10.3748/wjg.v20.i6.1517 | pmc=PMC3925860 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24587627  }} </ref><ref name="MajumdarBebb2007">{{cite journal|last1=Majumdar|first1=Debabrata|last2=Bebb|first2=James|last3=Atherton|first3=John|title=Helicobacter pylori infection and peptic ulcers|journal=Medicine|volume=35|issue=4|year=2007|pages=204–209|issn=13573039|doi=10.1016/j.mpmed.2007.01.006}}</ref></SMALL>
{|
| valign=top |
<div style="border-radius: 5px 5px 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
'''First line'''
</font>
</div>
<div class="mw-customtoggle-table01" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background:#4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Triple therapy'''
</font>
</div>
<div class="mw-customtoggle-table02" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background:#4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Quadruple therapy'''
</font>
</div>
<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
'''Second line'''
</font>
</div>
<div class="mw-customtoggle-table03" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background:#4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Triple therapy'''
</font>
</div>
<div class="mw-customtoggle-table04" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background:#4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Sequential therapy'''
</font>
</div>
<div class="mw-customtoggle-table05" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background:#4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Hybrid therapy'''
</font>
</div>
<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
'''Third line therapy (Rescue therapy)'''
</font>
</div>
<div class="mw-customtoggle-table06" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Rifabutin based'''
</font>
</div>
| valign=top |
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table01" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Triple therapy}}
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Lansoprazole]] 30 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Omeprazole]] 20 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Esomeprazole]] 40 mg q24h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Rabeprazole]] 20 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Clarithromycin]] 500 mg q12h.'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Amoxicillin]] 1 g q12h'''''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table02" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Quadruple therapy}}
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Bismuth subsalicylate]] 525 mg orally q6h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Metronidazol]] 250 mg orally q6h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Tetracycline]] 500 mg orally q6h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Ranitidine]] 150 mg orally q12h'''''<BR> OR <BR> ▸ '''''[[PPI]] standard dose'''''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table03" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Triple therapy}}
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Lansoprazole]] 30 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Omeprazole]] 20 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Esomeprazole]] 40 mg q24h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Rabeprazole]] 20 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Clarithromycin]] 500 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Metronidazole]] 500 mg q12h'''''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table04" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Sequential therapy}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''First 5 days'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Lansoprazole]] 30 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Omeprazole]] 20 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Esomeprazole]] 40 mg q24h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Rabeprazole]] 20 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Amoxicillin]] 1 g q12h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Next 5 days'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Lansoprazole]] 30 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Omeprazole]] 20 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Esomeprazole]] 40 mg q24h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Rabeprazole]] 20 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Clarithromycin]] 500 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Tinidazol]] 500 mg q12h'''''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table05" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Sequential therapy}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''First 7 days'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Lansoprazole]] 30 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Omeprazole]] 20 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Esomeprazole]] 40 mg q24h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Rabeprazole]] 20 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Amoxicillin]] 1 g q12h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Next 7 days'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[PPI]] standard dose'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Amoxicillin]] 1 g q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Clarithromycin]] 500 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Metronidazol]] 500 mg q12h'''''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table06" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Third line treatment}}
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Rifabutin]] 150 mg q2h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Amoxicillin]] 1 g IV q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Ciprofloxacin]] 500 mg/kg IV q12h'''''
|-
|}
|}
|}


==References==
==References==

Revision as of 13:46, 11 June 2014

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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

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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

  • 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.

Principles of Eradication Therapy for Helicobacter pylori infection

  1. Indications for diagnosis and treatment, established:[1]
    1. Active peptic ulcer disease.
    2. Confirmed history of peptic ulcer disease not previously treated for H. pylori.
    3. Gastric MALT lymphoma.
    4. After endoscopic resection of early gastric cancer.
    5. Uninvestigated dyspepsia (review H. pylori prevalence).
  2. Low clarithromycin resistance areas (<15%):[2]
    1. 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.
    2. 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.
  3. High clarithromycin resistance areas (≥15%):[2]
    1. In areas of high resistance, bismuth-containing quadruple therapy are recommended for first-line treatment.
    2. In areas of high resistance after failure of bismuth containing quadruple therapy, levofloxacin containing triple therapy is recommended.
  4. After failure of second-line treatment, treatment should be guided by antimicrobial susceptibility testing.[2]
  5. FDA approved first line regimens duration:[1]
    1. Triple therapy: 7 days (10 days if rabeprazole).
    2. Quadruple therapy: 4 weeks.
  6. Confirm the eradication of H. pylori infection in patients who have had an H. pylori-associated ulcer or gastric MALT lymphoma or who have undergone resection for early gastric cancer.[3]
  7. The urea breathing test is the most reliable nonendoscopic test to document eradication of H. pylori infection.[1]
  8. Testing to prove H. pylori eradication is most accurate if performed at 4 weeks after the completion of eradication therapy.[3]


Countries with a reported prevalence <15% of H. pylori resistance to clarithromycin[4][5][6][7]
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[4][5][6][7]
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.[1][8][9][3][10][11]

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
▸ Metronidazol 250 mg orally q6h
PLUS
▸ Tetracycline 500 mg orally q6h
PLUS
▸ Ranitidine 150 mg orally q12h
OR
▸ PPI standard dose
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
▸ Tinidazol 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
▸ Metronidazol 500 mg q12h
Third line treatment
▸ Rifabutin 150 mg q2h
PLUS
▸ Amoxicillin 1 g IV q12h
PLUS
▸ Ciprofloxacin 500 mg/kg IV q12h


References

  1. ↑ 1.0 1.1 1.2 1.3 Chey WD, Wong BC, Practice Parameters Committee of the American College of Gastroenterology (2007). "American College of Gastroenterology guideline on the management of Helicobacter pylori infection". Am J Gastroenterol. 102 (8): 1808–25. doi:10.1111/j.1572-0241.2007.01393.x. PMID 17608775.
  2. ↑ 2.0 2.1 2.2 Malfertheiner P, Megraud F, O'Morain CA, Atherton J, Axon AT, Bazzoli F; et al. (2012). "Management of Helicobacter pylori infection--the Maastricht IV/ Florence Consensus Report". Gut. 61 (5): 646–64. doi:10.1136/gutjnl-2012-302084. PMID 22491499.
  3. ↑ 3.0 3.1 3.2 McColl KE (2010). "Clinical practice. Helicobacter pylori infection". N Engl J Med. 362 (17): 1597–604. doi:10.1056/NEJMcp1001110. PMID 20427808.
  4. ↑ 4.0 4.1 Mégraud F (2004). "H pylori antibiotic resistance: prevalence, importance, and advances in testing". Gut. 53 (9): 1374–84. doi:10.1136/gut.2003.022111. PMC 1774187. PMID 15306603.
  5. ↑ 5.0 5.1 Duck WM, Sobel J, Pruckler JM, Song Q, Swerdlow D, Friedman C; et al. (2004). "Antimicrobial resistance incidence and risk factors among Helicobacter pylori-infected persons, United States". Emerg Infect Dis. 10 (6): 1088–94. doi:10.3201/eid1006.030744. PMC 3323181. PMID 15207062.
  6. ↑ 6.0 6.1 De Francesco V, Giorgio F, Hassan C, Manes G, Vannella L, Panella C; et al. (2010). "Worldwide H. pylori antibiotic resistance: a systematic review". J Gastrointestin Liver Dis. 19 (4): 409–14. PMID 21188333.
  7. ↑ 7.0 7.1 Boyanova L, Mitov I (2010). "Geographic map and evolution of primary Helicobacter pylori resistance to antibacterial agents". Expert Rev Anti Infect Ther. 8 (1): 59–70. doi:10.1586/eri.09.113. PMID 20014902.
  8. ↑ Garza-González E, Perez-Perez GI, Maldonado-Garza HJ, Bosques-Padilla FJ (2014). "A review of Helicobacter pylori diagnosis, treatment, and methods to detect eradication". World J Gastroenterol. 20 (6): 1438–49. doi:10.3748/wjg.v20.i6.1438. PMC 3925853. PMID 24587620.
  9. ↑ O'Connor A, Molina-Infante J, Gisbert JP, O'Morain C (2013). "Treatment of Helicobacter pylori infection 2013". Helicobacter. 18 Suppl 1: 58–65. doi:10.1111/hel.12075. PMID 24011247.
  10. ↑ Song M, Ang TL (2014). "Second and third line treatment options for Helicobacter pylori eradication". World J Gastroenterol. 20 (6): 1517–28. doi:10.3748/wjg.v20.i6.1517. PMC 3925860. PMID 24587627.
  11. ↑ Majumdar, Debabrata; Bebb, James; Atherton, John (2007). "Helicobacter pylori infection and peptic ulcers". Medicine. 35 (4): 204–209. doi:10.1016/j.mpmed.2007.01.006. ISSN 1357-3039.


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