Gastritis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Aravind Reddy Kothagadi M.B.B.S[2]
Work in progress...
Overview
Medical therapy for gastritis depends on the cause but commonly includes reducing stomach acidity (e.g., with proton pump inhibitors) or eradicating H. pylori infection with antibiotics.
Medical Therapy
Treatment depends on the specific cause. Some of the causes will disappear over time.
- Medications known to cause gastritis should be discontinued.
- Medications to neutralize stomach acid or decrease its production will usually eliminate the symptoms and promote healing.
- Vitamin B12: Gastritis caused by pernicious anemia is treated with vitamin B12.
- Proton pump inhibitors: Gastritis due to stress is best treated by prevention. Medications to decrease gastric acid production such as proton pump inhibitors (PPI) should be given to stressed hospital patients.
- Antibiotics: In cases of infection, a doctor will most often prescribe antimicrobial drugs. Helicobacter infection typically responds well to the triple therapy protocol (consisting of two antibiotics, and a proton pump inhibitor). Regimens that work well include PCA or PCM triple therapy (PPI, Clarithromycin, Amoxicillin) or (PPI, Clarithromycin, Metronidazole). Quadruple therapy has a >90% success rate and includes PPIs, Bismuth subsalicylates, Metronidazole, and Tetracycline.
Overview
Indications for treatment of H. pylori infection include past or present duodenal and/or gastric ulcer, with or without complications, following resection of gastric cancer, gastric mucosa-associated lymphoid tissue (MALT) lymphoma, atrophic gastritis, dyspepsia, patients with first-degree relatives with gastric cancer and patient‘s wishes. Factors involved in choosing treatment regimens include prevalence of H. pylori infection, prevalence of gastric cancer, resistance to antibiotics, availability of bismuth, availability of endoscopy and H. pylori tests, ethnicity, drug allergies and tolerance, previous treatments and outcome, adverse effects, effectiveness of local treatment and recommended dosages and treatment duration.
Medical Therapy
Indications for treatment of H. pylori infection include:[1]
- Past or present duodenal and/or gastric ulcer, with or without complications
- Following resection of gastric cancer
- Gastric mucosa-associated lymphoid tissue (MALT) lymphoma
- Atrophic gastritis
- Dyspepsia
- Patients with first-degree relatives with gastric cancer
- Patients wishes
Factors involved in choosing treatment regimens include:[1]
- Prevalence of H. pylori infection
- Prevalence of gastric cancer
- Resistance to antibiotics
- Availability of bismuth
- Cost of tests
- Availability of endoscopy and H. pylori tests
- Ethnicity
- Drug allergies and tolerance
- Previous treatments and outcome
- Ease of administration
- Adverse effects
- Effectiveness of local treatment
- Recommended dosages and treatment duration
First-Line Regimens for Helicobacter pylori Eradication
- Bismuth quadruple therapy has been advocated as a primary therapy for H. pylori.
- In patients who have not previously received clarithromycin and who are not allergic to penicillin, PPI, clarithromycin, and amoxicillin are considered.
- For patients allergic to penicillin, metronidazole is given as an alternative for amoxicillin.
- In patients who are allergic to penicillin or those who have previously been treated with a macrolide antibiotic, bismuth quadraple therapy is considered.
| Regimen | Duration | Eradication rates | Comments |
|---|---|---|---|
| Standard dose PPI b.i.d. (esomeprazole is q.d.),
clarithromycin 500 mg b.i.d., amoxicillin 1,000 mg b.i.d. |
10–14 | 70–85% | Consider in nonpenicillin allergic patients who have not previously received a macrolide |
| Standard dose PPI b.i.d., clarithromycin 500 mg b.i.d.
metronidazole 500 mg b.i.d. |
10–14 | 70–85% | Consider in penicillin allergic patients who have not previously received a macrolide or are unable to tolerate bismuth quadruple therapy |
| Bismuth subsalicylate 525 mg p.o. q.i.d. metronidazole
250 mg p.o. q.i.d., tetracycline 500 mg p.o. q.i.d., ranitidine 150 mg p.o. b.i.d. or standard dose PPI q.d. to b.i.d. |
10–14 | 75–90% | Consider in penicillin allergic patients |
| PPI + amoxicillin 1 g b.i.d. followed by
PPI, clarithromycin 500 mg, tinidazole 500 mg b.i.d. |
5
5 |
>90% | Requires validation in North America |
| PPI = proton pump inhibitor; pcn = penicillin; p.o. = orally; q.d. = daily; b.i.d. = twice daily; t.i.d. = three times daily; q.i.d. = four times daily.
*Standard dosages for PPIs are as follows: lansoprazole 30 mg p.o., omeprazole 20 mg p.o., pantoprazole 40 mg p.o., rabeprazole 20 mg p.o., esomeprazole 40 mg p.o. Note: the above-recommended treatments are not all FDA approved. | |||
FDA approved regimens are as follows:
1. Bismuth 525 mg q.i.d. + metronidazole 250 mg q.i.d. + tetracycline 500 mg q.i.d. × 2 wk + H2RA as directed × 4 wk.
2. Lansoprazole 30 mg b.i.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 10 days.
3. Omeprazole 20 mg b.i.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 10 days.
4. esomeprazole 40 mg q.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 10 days.
5. Rabeprazole 20 mg b.i.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 7 days.
Predictors of H.pylori Treatment Outcome
Predictors of treatment failure include:
- Poor compliance
- Antibiotic resistance (key factor in the failure of eradication therapy and recurrence of H. pylori infection)
- Bacterial factors like CagA-negative strains are at increased risk of treatment failure compared with CagA-positive strains
- CYP2C 19 polymorphisms may influence treatment outcomes when regimens containing PPIs are used as they influence the clearance of PPIs and thus their effect on gastric acid secretion.
| Drugs | Side effects | Recommendations |
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| Proton pump inhibitors (PPIs) |
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PPIs should be taken 30-60 min before eating to optimize their effects on gastric acid secretion. |
| Clarithromycin |
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| Amoxicillin |
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| Metronidazole |
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| Tetracycline |
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Tetracyclinhes should not be given to children under 8 yr of age because of possible tooth discoloration |
| Bismuth Compounds |
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Salvage Therapy for Persistent H.pylori Infection
- In patients with persistent H. pylori infection, every effort should be made to avoid antibiotics that have been previously taken by the patient.[2]
- Bismuth-based quadruple therapy for 7-14 days is an accepted salvage therapy.
- Levofloxacin-based triple therapy for 10 days is another option in patients with persistent infection, which requires validation in the United States.
| Regimen | Duration | Eradication rates | Comments |
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| Bismuth quadruple therapy
PPI q.d. tetracycline, Pepto Bismol, metronidazole q.i.d. |
7 | 68% | Accessible, cheap but high pill count, and frequent mild side effects |
| Levofloxacin triple therapy
PPI, amoxicillin 1 g b.i.d., levofloxacin 500 mg q.d. |
10 | 10 87% | Requires validation in North America |
- Triple therapy should be used if a patient has persistent infection who has previously not been treated with clarithromycin.
- In patients who were treated with clarithromycin initially, bismuth quadruple therapy is used as salvage therapy.
Other Alternative Antibiotics
Rifabutin
- Rifabutin is used as an alternate antibiotic in patients with clarithromycin or metronidazole resistance.[3][4][5][6][7]
- Side effects include rash, nausea, vomiting, dyspepsia, diarrhea, myelotoxicity and ocular toxicity
Furazolindone
- Furazolidone is used as an alternative to clarithromycin, metronidazole, or amoxicillin[2][8][9]
- Not currently used in the United states
- Side effects include nausea, vomiting, headache and malaise
Levofloxacin
- Levofloxacin-based triple therapy (PPI, levofloxacin, and amoxicillin) can be used as second and third-line therapy in patients with persistent H. pylori infection.[10][11][12]
H.pylori Treatment Options in Developing Countries
H. pylori treatment options in developing countries include:[1]
| First-Line therapies | ||
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| PPI + amoxicillin + clarithromycin
(All twice daily for 7 days) |
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| In case of a clarithromycin resistance rate of more than 20%:
Quadruple therapy: PPI b.i.d. + bismuth + tetracycline + metronidazole all q.i.d. for 7 - 10 days |
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If there is no known clarithromycin resistance or clarithromycin resistance is not likely:
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| B Second-line therapies, after failure of clarithromycin incontaining regimens | ||
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| C Third-line therapies, after failure of clarithromycin-containing regimens and quadruple therapy | ||
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B.i.d (twice a day); q.i.d (four times a day); PPI, proton-pump inhibitor
Testing to Prove Eradication After Antibiotic Therapy
The following are the indications for testing to prove eradication after antibiotic therapy.[13]
- Any patient with an H.pylori-associated ulcer.
- Individuals with persistent dyspeptic symptoms despite the test-and-treat strategy.
- Those with H.pylori associated MALT lymphoma.
- Individuals who have undergone resection of early gastric cancer.
References
- ↑ 1.0 1.1 1.2 Hunt RH, Xiao SD, Megraud F, Leon-Barua R, Bazzoli F, van der Merwe S; et al. (2011). "Helicobacter pylori in developing countries. World Gastroenterology Organisation Global Guideline". J Gastrointestin Liver Dis. 20 (3): 299–304. PMID 21961099.
- ↑ 2.0 2.1 Isakov V, Domareva I, Koudryavtseva L, Maev I, Ganskaya Z (2002). "Furazolidone-based triple 'rescue therapy' vs. quadruple 'rescue therapy' for the eradication of Helicobacter pylori resistant to metronidazole". Aliment Pharmacol Ther. 16 (7): 1277–82. PMID 12144577.
- ↑ Miehlke S, Hansky K, Schneider-Brachert W, Kirsch C, Morgner A, Madisch A; et al. (2006). "Randomized trial of rifabutin-based triple therapy and high-dose dual therapy for rescue treatment of Helicobacter pylori resistant to both metronidazole and clarithromycin". Aliment Pharmacol Ther. 24 (2): 395–403. doi:10.1111/j.1365-2036.2006.02993.x. PMID 16842467.
- ↑ Perri F, Festa V, Clemente R, Villani MR, Quitadamo M, Caruso N; et al. (2001). "Randomized study of two "rescue" therapies for Helicobacter pylori-infected patients after failure of standard triple therapies". Am J Gastroenterol. 96 (1): 58–62. doi:10.1111/j.1572-0241.2001.03452.x. PMID 11197288.
- ↑ Bock H, Koop H, Lehn N, Heep M (2000). "Rifabutin-based triple therapy after failure of Helicobacter pylori eradication treatment: preliminary experience". J Clin Gastroenterol. 31 (3): 222–5. PMID 11034001.
- ↑ Wong WM, Gu Q, Lam SK, Fung FM, Lai KC, Hu WH; et al. (2003). "Randomized controlled study of rabeprazole, levofloxacin and rifabutin triple therapy vs. quadruple therapy as second-line treatment for Helicobacter pylori infection". Aliment Pharmacol Ther. 17 (4): 553–60. PMID 12622764.
- ↑ Borody TJ, Pang G, Wettstein AR, Clancy R, Herdman K, Surace R; et al. (2006). "Efficacy and safety of rifabutin-containing 'rescue therapy' for resistant Helicobacter pylori infection". Aliment Pharmacol Ther. 23 (4): 481–8. doi:10.1111/j.1365-2036.2006.02793.x. PMID 16441468.
- ↑ Ali BH (1999). "Pharmacological, therapeutic and toxicological properties of furazolidone: some recent research". Vet Res Commun. 23 (6): 343–60. PMID 10543364.
- ↑ Wong WM, Wong BC, Lu H, Gu Q, Yin Y, Wang WH; et al. (2002). "One-week omeprazole, furazolidone and amoxicillin rescue therapy after failure of Helicobacter pylori eradication with standard triple therapies". Aliment Pharmacol Ther. 16 (4): 793–8. PMID 11929398.
- ↑ Saad RJ, Schoenfeld P, Kim HM, Chey WD (2006). "Levofloxacin-based triple therapy versus bismuth-based quadruple therapy for persistent Helicobacter pylori infection: a meta-analysis". Am J Gastroenterol. 101 (3): 488–96. doi:10.1111/j.1572-0241.1998.455_t.x. PMID 16542284.
- ↑ Gisbert JP, Morena F (2006). "Systematic review and meta-analysis: levofloxacin-based rescue regimens after Helicobacter pylori treatment failure". Aliment Pharmacol Ther. 23 (1): 35–44. doi:10.1111/j.1365-2036.2006.02737.x. PMID 16393278.
- ↑ Gisbert JP, Castro-Fernández M, Bermejo F, Pérez-Aisa A, Ducons J, Fernández-Bermejo M; et al. (2006). "Third-line rescue therapy with levofloxacin after two H. pylori treatment failures". Am J Gastroenterol. 101 (2): 243–7. doi:10.1111/j.1572-0241.2006.00457.x. PMID 16454825.
- ↑ Laine L, Sugg J, Suchower L, Neil G (2000). "Endoscopic biopsy requirements for post-treatment diagnosis of Helicobacter pylori". Gastrointest Endosc. 51 (6): 664–9. PMID 10840297.