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.