Helicobacter Pylori (HP) eradication continues to pose some challenges as “standard” treatment fails. Treatment failure is said to be due to resistance of HP to the antibiotics used in this regimen. Before we examine the advances in treatment options, let us briefly review treatment indications.
The prevalence of HP infection in the Australian community is approximately 20% or less. Only a small minority of the infected population get symptoms. Also we need to be cognizant of the probable beneficial effect of HP in reflux oesophagitis, Barrett’s oesophagus, asthma, atopic diseases and side effects of eradication therapy.
Indication for HP eradication: These include peptic ulcer disease, non-ulcer dyspepsia, gastric MALT lymphoma, family history of gastric cancer, hypertrohic gastritis (Menetrier’s disease), prior to long term NSAID therapy, prior to long term PPI treatment , gastric atrophy, intestinal metaplasia and dysplasia (1).
Standard treatment: this includes PPI, Clarithromycin and Amoxicillin for 10-14 days (2). The alternative is bismuth based quadruple therapy ( PPI, Bismuth, tetra- cycline and metronidazole) for 14 days with substantial side effects. The cure rate of standard triple therapy is just under 80%. In the Australian context, standard therapy is a 7 day pack of esomeprazole , Clarithromycin and Amoxicillin .
Causes of failure of standard triple therapy: Failure is attributed to re- sistance of HP to Clarithromycin in the order of 15-20% and in upto 40% of cases to metronidazole. Amoxyillin is essentially unaffected with 1% resistance from HP. So what is the way ahead?
Sequential therapy: uses a PPI and Amoxicillin 1 gm twice daily for 5 days fol- lowed by PPI, Clarithromycin 500mg and Tinidazole 500mg each twice daily for an additional 5 days. Eradication rates are between 91-93% in 22 trials which included a total of 2388 patients (3). Response to sequential therapy in patients with non- ulcer dyspepsia is twice (90% vs. 40%) as good when compared to standard triple therapy (3).
Concomitant therapy: utilizes 4 agents such as PPI, Clarithromycin, Metronida- zole and Amoxicillin for 9-14 days. Eradication rates of 90% have been claimed (4). Experience demonstrates that 4 agent regimens have more side effects than triple agent therapy thus decreasing compliance.
Salvage therapy: Also called the second line treatment includes substitution of Clarithromycin with Levofloxacin (ciprofloxacin in Australian context) or Rifabutin. This regimen includes PPI, Amoxicillin, levofloxacin (or Ciprofloxacin 250mg twice daily) or Rifabutin 300mg 4 times a day. In the sequential therapy setting, trials have compared Clarithromycin regimen with regimen replacing Clarithromycin with Levofloxacin with Levofloxacin arm achieving 98% cure rate compared to 83% with Clarithromycin (5) . Development of resistance to levofloxacin is an issue and myelosuppression with Rifabutin needs to be watched for.
Please remember to check for HP eradication 6-8 weeks after treatment.
- Talley NJ et al. Guideline for the management of dyspepsia. Am J Gastroenterology 2005;100:2324-37.
- Malfertheiner P et al. Current concepts in the management of Helicobacter Pylori infection: the Maastricht III Concensus Re- port. Gut 2007;56:772-81.
- Vaira D et al. Sequential therapy for H. Pylori eradication: The time is now! Therap Adv Gastroenterology 2009; 2:317-22.
- Vakil N et al. Eradication therapy for H. Pylori: Gastroenterolo- gy 2007; 133:985-1001.
- Romano M et al. Empirical Levofloxacin-containing versus Clar- ithromycin –containing sequential therapy for Helicobacter Pylori : a randomized trial: Gut 2010; 59:1465-70.
Editorial: Provision of both gastroscopy and colonoscopy in the same patient on the same day.
There was a time when two thirds of our endoscopy lists were full of patients wanting both a gastroscopy and a colonoscopy on the same day. The vast majority of these patients needed either a gastroscopy or a colonoscopy done based on symptoms and wanted “ the other end checked since I am there”. The consequence of filling up endoscopy lists with unnecessary double procedures was that pa- tients who truly needed a focused symptom based procedure such as either a gastroscopy or a colonoscopy, were delayed and some ended up in the hospital due to aggravation of their condition while waiting for the procedure. This realization led us to limit the number of double procedures we do in individual patients in any one endoscopy list and instead give priority to individual symptom based focused referrals for either a gastrocopy or a colonoscopy. While we are continu- ing to provide 3-4 double procedures in every endoscopy list every day, the emphasis has shifted to careful triaging such that focused single pro- cedures are given priority and at the same time offer patients who want both ends checked on the same day to consider getting the most im- portant of the two procedures done first followed by the second proce- dure on a different day or wait to get both procedures done on the same day. There are always cancellations and we are able to accommodate a gastrosco- py or a colonoscopy in a cancelled slot within 2 weeks of referral. This strategy appears to be working. Yet we appreciate that there would be some pa- tients whose symptoms are vague and would require both ends checked preferably the same day and we continue to prioritize these patients and do their double procedures the same day soonest possible. I hope this strategy meets with your approval.
Please do not hesitate to contact me ( 07 5531 7809) or our staff to leave a message for me to call you back should you have specific concerns about any of your patients. Our fees remain the lowest in Gold Coast and quality of our service is second to none. We continue to provide complex procedures such as endoscopic mucosal resection and ERCPs from Allamanda Hospital.