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: Manpreet Kaur, MD [2]

Overview

Eradication of Helicobacter pylori with antimicrobial agents is indicated for patients with gastric or duodenal peptic ulceration, who are colonized with H. pylori, and patients with MALT lymphoma. Eradication therapy should also be considered in patients with immune thrombocytopenic purpura who are H. pylori-positive and patients who have undergone resection for early-stage gastric cancer. Pharmacologic therapies for peptic ulcer disease due to H. pylori is either triple or quadruple pharmacologic agents that include a Proton pump inhibitors plus a combination of antimicrobial agents. The use of antimicrobial therapy is discouraged among asymptomatic carriers.

Medical Therapy

Treatment strategies

• The use of high-dose (twice a day) proton pump inhibitor (PPI) increases the efficacy of triple therapy.
• In areas of low clarithromycin resistance, clarithromycin-containing treatments (PCA or PCM) are recommended for first-line empirical treatment. Bismuth-containing quadruple treatment is also an alternative.
• In areas of high clarithromycin resistance, bismuth-containing quadruple treatment is recommended for first-line empirical treatment. If this regimen is not available, sequential treatment is recommended.
• Extending the duration of triple treatment from 7 to 10–14 days improves the eradication success rate and may be considered.
• After failure of a PPI-clarithromycin containing therapy, either a bismuth-containing quadruple treatment or levofloxacin-containing triple therapy (PLA) is recommended.
• After failure of second-line treatment, treatment should be guided by antimicrobial susceptibility testing whenever possible.
• The urea breath test or a laboratory based validated monoclonal stool test are both recommended as non-invasive tests for determining the success of eradication treatment.

Eradication Therapy for Helicobacter pylori Infection

Triple Therapy

• PCA regimen

• Preferred regimen (1):Proton pump inhibitor (standard dose twice daily) for 7–14 days AND
• Note: Lansoprazole 30 mg q12h, or Omeprazole 20 mg q12h, or Esomeprazole 40 mg q24h, or Rabeprazole 20 mg q12h
• Preferred regimen (1):Clarithromycin (500 mg twice daily) for 7–14 days AND
• Preferred regimen (1):Amoxicillin (1 g twice daily) for 7–14 days OR Metronidazole (250 mg four times daily) for 7–14 days

• PCM regimen

• Alternative regimen (1): Proton pump inhibitor (standard dose twice daily) for 7–14 days AND
• Alternative regimen (1): Clarithromycin (500 mg twice daily) for 7–14 days AND
• Alternative regimen (1): Metronidazole (250 mg four times daily) for 7–14 days

• PLA regimen

• Alternative regimen (1): Proton pump inhibitor (standard dose twice daily) for 10 days AND
• Alternative regimen (1): Levofloxacin (500 mg twice daily) for 10 days AND
• Alternative regimen (1): Amoxicillin (1 g twice daily) for 10 days

• PMA regimen

• Alternative regimen (1): Proton pump inhibitor (standard dose twice daily) for 7–14 days AND
• Alternative regimen (1): Metronidazole (250 mg four times daily) for 7–14 days AND
• Alternative regimen (1): Amoxicillin (1 g twice daily) for 7–14 days

• PRA regimen

• Alternative regimen (1): Proton pump inhibitor (standard dose twice daily) for 10 days AND
• Alternative regimen (1): Rifabutin (150–300 mg/day) for 10 days AND
• Alternative regimen (1): Amoxicillin (1 g twice daily) for 10 days

Quadruple Therapy

Bismuth-Containing Quadruple Therapy

• Bismuth quadruple therapy

• Preferred regimen (1): Proton pump inhibitor (standard dose twice daily) for 10–14 days AND
• Preferred regimen (1): Metronidazole (250 mg four times daily) for 10–14 days AND
• Preferred regimen (1): Tetracycline (500 mg four times daily) for 10–14 days AND
• Preferred regimen (1): Bismuth (dose depends on preparation) for 10–14 days

Non–Bismuth-Containing Quadruple Therapy

• Concomitant therapy

• Alternative regimen (1): Proton pump inhibitor (standard dose twice daily) for 7–14 days AND
• Alternative regimen (1): Clarithromycin (500 mg twice daily) for 7–14 days AND
• Alternative regimen (1): Amoxicillin (1 g twice daily) for 10 days AND
• Alternative regimen (1): Metronidazole (250 mg four times daily) for 7–14 days

• Sequential therapy

• Alternative regimen (1): Proton pump inhibitor (standard dose twice daily) for 5 days AND
• Alternative regimen (1): Amoxicillin (1 g twice times daily) for 5 days
  FOLLOWED BY
• Alternative regimen (1): Proton pump inhibitor (standard dose twice daily) for another 5 days AND
• Alternative regimen (1): Clarithromycin (500 mg twice daily) for another 5 days AND
• Alternative regimen (1): Tinidazole (500 mg twice daily) for another 5 days

Contraindicated Medications

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

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

Guidelines and Resources

• American College of Gastroenterology (ACG) – Guidelines for the management of dyspepsia.
• American Society for Gastrointestinal Endoscopy (ASGE) – The role of endoscopy in dyspepsia.
• American Society for Gastrointestinal Endoscopy (ASGE) – The role of endoscopy in gastroduodenal obstruction and gastroparesis.
• American College of Cardiology Foundation/American College of Gastroenterology/American Heart Association (ACCF/ACG/AHA) – Reducing the gastrointestinal risks of antiplatelet therapy and NSAID use.
• The European Helicobacter Study Group (EHSG) – Management of Helicobacter pylori infection.