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Treatment of Helicobacter pylori in association with Peptic Ulcer Disease

Dr. K. Shalansky, C. Hughes, Dr. P. Loewen, Pharmacy
June 1997 Drug & Therapeutics Newsletter
(C) 1997, CSU-Pharmaceutical Sceinces
Vancouver Hospital & Health Sciences Centre

It is now accepted that the majority of peptic ulcers occur secondary to either H. pylori infection or non-steroidal anti-inflammatory drugs (NSAIDs).1 H. pylori is a gram negative bacillus which colonizes the human gastric mucosa.2 The percentage of peptic ulcers associated with H. pylori infection is as follows3:

Gastric ulcers (GU): ~ 70%
Duodenal ulcers (DU): > 95%

Indications for anti-H. Pylori Therapy

All patients with a documented DU or GU associated with H. pylori infection should receive antimicrobial therapy. The presence of H. pylori can be determined by endoscopy with biopsy or non-invasively through serologic antibody testing or breath tests for urea.1,3 For practical purposes, in patients with an uncomplicated DU, empiric antibiotic therapy without H. pylori testing has been advocated due to the high association with this organism.3,4

Treatment Strategies for H. pylori

According to the consensus guidelines, two regimens are currently recommended for eradication of H. pylori (Table 3).3,5 Both regimens are effective with one week of therapy. The addition of omeprazole in the quadruple regimen enhances symptom relief and improves eradication by ~ 5%.

Quadruple therapy is considered the "gold standard" regimen, however, patient compliance may be hindered by its complexity. Triple therapy offers a simpler BID regimen, albeit slightly less efficacious and more expensive. Dual therapy with omeprazole plus amoxicillin 1g BID or clarithromycin 500mg TID x 2 weeks are not recommended due to lower success rates of 50-80%.

Adverse effects (primarily metallic taste, nausea and diarrhea) result in ~ 5% patient withdrawal. Clarithromycin inhibits the Cyp 3A enzyme system which can result in toxic levels of cyclosporine, theophylline, cisapride, and non-sedating antihistamines (terfenadine, astemizole).

Table 3: Eradication of H. pylori infection: regimens and costs

Recommended Regimens

(x 7 days)

Success Rate Cost/7 days1
QUADRUPLE THERAPY

Bismuth Subsalicylate 30mL (or ii tablets) QID

Metronidazole 250mg QID Tetracycline 500mg QID

Omeprazole 20mg BID

94-98% $44.61

$12.13

$0.56

$1.12

$30.80

TRIPLE THERAPY

Metronidazole 500mg BID (or Amoxicillin 1g BID)

Clarithromycin 500mg BID

Omeprazole 20mg BID

86-91% $72.76 or $74.70

$0.56

($2.40)

$41.40

$30.80

1 based on VHHSC acquisition cost

Follow-up

Once cure has been achieved, reinfection rates are less than 0.5%.3 Eradication of H. pylori should be confirmed 4 weeks after completion of antibiotic treatment for complicated, large or refractory ulcers. Antisecretory therapy should be continued until H. pylori cure has been confirmed in these cases. Once ulcer healing is complete and H. pylori eradicated, maintenance antisecretory therapy (e.g. ranitidine 150mg HS) is only warranted in high risk patients where recurrence of bleeding may cause death.3

References

  1. Anon. Drugs for treatment of peptic ulcers. Med Lett Drugs Ther 1994;36(issue 927):65-7.
  2. Burette A, Glupczynski Y. Infection 1995;23:S44-S52.
  3. Soll AH. Medical treatment of peptic ulcer disease. JAMA 1996;275:622-9.
  4. Rauws EAJ, van der Hulst RWM. Current guidelines for the eradication of Helicobacter pylori in peptic ulcer disease. Drugs 1995;50:984-90.
  5. Walsh JH, Peterson WL. The treatment of Helicobacter pylori infection in the management of peptic ulcer disease. NEJM 1996;333:984-91.