Skip to main content

Management of H.pylori and NSAID-associated ulcers Eradication!

MANAGEMENT FOR H.PYLORI ERADICATION



  • It is known that H.pylori infection is associated with over 90% of duodenal ulcers and 80% of Gastric Ulcers.
  • Antibiotics alone or acid-suppressing agents alone, do not eradicate H.pylori.
  • Both therapies act synergistically as growth of the organism occurs at elevated pH and antibiotics efficacy is enhanced during growth. Additionally, increasing intragastric pH may enhance antibiotic absorption.
  • High eradication rates are achieved by a short course of Triple Therapy consisting of:
           1.PPI                                         2. Clarithromycin                         3. Amoxicillin/Metronidazole
         in a twice recommended simultaneous regimen.


First-Line Therapy: 

European Guidelines recommended 1 week of therapy, whereas the US Guidelines recommend 10-14 days of therapy and achieve 7-9% better eradication rates.
    OCA: Omeprazole(20mg), Clarithromycin (500mg) and Amoxicillin (1g) 
                                                       or
   OCM: Omeprazole (20mg), Clarithromycin (250mg) and Metronidazole (400mg)

  • A lower dose of Clarithromycin (250mg twice daily) is effective and recommended when combined with Metronidazole. (NICE,2004).
  • Omeprazole may be replaced with any of the other PPI drugs.
  • Local resistance rates determine the most appropriate First-line regimens with OCA preferred in areas of high metronidazole resistance.
In the UK, resistance to metronidazole has been reported in about 50% of H.pylori isolates and resistance to Clarithromycin in about 10%. Resistance to Amoxicillin is rare.

  • In patients with hypersensitivity to Penicillin, the OCM regimen or substitution of Amoxicillin from the OCA regimen with Tetracycline 500mg twice daily is used. If patients have recently received antibiotic treatment for any indication, a regimen avoiding that antibiotic is preferred.

Second-Line Therapy:

  • Failure of the first-line regimen to achieve eradication will necessitate treatment with another Triple-Therapy regimen or with a Bismuth-Based Quadruple regimen.
  • Recommended Second-Line therapy regimen include:
              PPI, Amoxicillin or Tetracycline and Metronidazole.

  • Most four-drug regimens contain Bismuth Subsalicylate, Metronidazole, Tetracycline or Amoxicillin and PPI and are generally not well tolerated by patients as Triple-Therapy regimen.

  • Successful eradication relies upon patients adhering to their medication regimen. It is therefore important to educate patients about the principle of eradication therapy and also about coping with common adverse effects associated with their regimen.
  • Diarrhea is the most common adverse effect and should subside after treatment is complete.
  • If eradication is successful, uncomplicated active peptic ulcers heal without the need to continue ulcer-healing drugs beyond the duration of eradication therapy.
  • Patients with persistent symptoms after eradication therapy should have their H.pylori status rechecked.
  • This should be carried out no sooner than 4 weeks after discontinuation of therapy to avoid false-negative results due to suppression rather than eradication of the organism.
  • If the patient is H.pylori positive, an alternate eradication regimen should be given. If eradication was successful but symptoms persist, gastro-esophageal reflux or other causes of dyspepsia should be considered.


MANAGEMENT OF NSAID-ASSOCIATED ULCERS


  • The NSAID-associated ulcers may be H.pylori positive. Eradication is generally recommended in infected patents with NSAID-associated ulcers as it is difficult to differentiate between H.pylori  or NSAID as the cause of the ulcer.
  • If NSAID are discontinued, most uncomplicated ulcers heal using standard doses of a PPI, H-receptor antagonist, Misoprostol or Sucralfate.
  • Healing is impaired if NSAID use is continued.
  • PPIs demonstrate a higher healing rate at 4 weeks but similar healing rates to H2-receptor antagonist at 8 weeks.



Labels:

Comments

Post a Comment

Popular posts from this blog

General Mechanism of Actions of INSULIN.

GENERAL MECHANISM OF ACTION OF INSULIN AND RELATE HORMONES The body's main fuel is Glucose. Glucose is stored in the liver and muscles as Glycogen.  Excess glucose is stored in the adipose tissues which yield fatty acids via lipolysis. In the fasting state, free fatty acids supply much of the energy needs of the body except for the CNS which requires Glucose to function normally. Proteins can also be converted to glucose via gluconeogenesis. RELEASE OF INSULIN AND GLUCAGON Insulin and Glucagon are produced in the pancreas by the Islets of Langerhans . Beta cells   make up 70%-90% of the Islets and produce Insulin and Amylin while the a-cells   produce glucagon. The main function of insulin is to decrease blood glucose levels. Glucagon, along with other counter-regulatory hormones such as growth factor, cortisol, and Epinephrine, increases Blood glucose levels.  The opposing actions of Glucagon and Insulin along with other counter-regulatory hormones maintain a norma...
Post a Comment
Read more

Diabetes Mellitus: Its Goals Of Therapy!

  GOAL OF THERPY The goals of treatment of DM includes; Reducing, controlling and managing long-term microvascular, macrovascular and neuropaathic complications. Preserving beta cell function. Preventing acute complications from increased Blood glucosel level. Minimizing hypoglycemic episodes. Maintaining patient quality of life. --Two landmark trials, THE DIABETES CONTROL AND COMPLICATION TRIAL (DCCT) and THE UNITED KINGDOM PROSPECTIVE DIABETES STUDY(UKPDS), showed that lowering blood glucose levels decreased the risk of developing chronic complications. --A near normal blood glucose level can be achieved with appropriate patient education , lifestyle modification and medications . --Proper care of DM requires goal setting and assessment for glycemic control , self-monitoring of blood glucose (SMBG) monitoring of blood glucose pressure , and lipid levels , regular monitoring for the development of complications , dietary and exercise lifestyle modifications and proper medicatio...
Post a Comment
Read more

Diabetes Mellitus: Clinical Presentation and Diagnosis!

 CLINICAL PRESENTATION AND DIAGNOSIS OF DM 2. SCREENING American Diabetes Association (ADA) recommends routine screening for T2 DM every 3 years in all adults starting at 45 years of age. Testing of T2 DM should be considered in any adult, regardless of their age, who have a BMI greater than or equal to 25kg/m2. The ADA does not currently recommend widespread screening for T1 DM because of the relatively low incidence in the general population, although measurement of Islet antibodies may be appropriate for high-risk individuals. 3.GESTATIONAL DIABETES: "Gestational diabetes is the glucose intolerance in women during pregnancy". All pregnant women who have risk factors for T2 DM should be screened for undiagnosed T2 DM at their first prenatal visit using standard diagnostic criteria.  Any women found to have diabetes in the early point at pregnancy is considered to have T2 DM or GDM. All other pregnant women, not currently known to have DM should be screened for GDM with a 75...
Post a Comment
Read more