Peptic ulcer medical therapy: Difference between revisions

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Latest revision as of 23:37, 29 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Manpreet Kaur, MD [2]

Overview

The mainstay of treatment for peptic ulcer disease is pharmacotherapy. Treatment of Helicobacter pylori with antimicrobial agents is indicated for patients with gastric or duodenal ulceration. 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. After the first line therapy, patient is tested for persistent H.pylori infection. If the patient has persistent infection, treatment is planned according to previous antibiotics therapy. Salvage treatment is used for failure of first line therapy. The use of antimicrobial therapy is discouraged among asymptomatic carriers.

Medical Therapy

The mainstay of treatment for peptic ulcer disease is pharmacotherapy. Pharmacotherapy for peptic ulcer disease can be discussed under Helicobacter pylori-associated peptic ulcer and Non- Helicobacter pylori-associated peptic ulcer disease.

Eradication Therapy for Helicobacter pylori Infection

The ACG’s 2017 treatment guideline on the management of H. pylori infection listed the following as established indications for diagnosis and treatment:^[1]

Indications

Active Peptic ulcer disease (gastric or duodenal).
Confirmed history of PUD (not previously treated for H. pylori)
Gastric MALT lymphoma (low grade)
After endoscopic resection of gastric cancer

Depending upon exposure of antibiotics and allergy to antibiotics, following treatments regimen are being used:^[2]^[3]

Triple Therapy

Triple therapy consisting of a Proton pump inhibitors and 2 antibiotics for 14 days remains a recommended treatment in regions where H. pylori clarithromycin resistance is known to be <15% and in patients with no previous history of macrolide exposure.^[4]^[5]^[6]
PCA regimen

Preferred regimen (1):Proton pump inhibitor standard dose* PO q12h for 7–14 days AND
Preferred regimen (2):Clarithromycin 500 mg PO q12h for 7–14 days AND
Preferred regimen (3):Amoxicillin 1 g PO q12h for 7–14 days OR Metronidazole 250 mg PO q6h for 7–14 days

PCM regimen

Alternative regimen (1): Proton pump inhibitor standard dose* PO q12h for 7–14 days AND
Alternative regimen (2): Clarithromycin 500 mg PO q12h for 7–14 days AND
Alternative regimen (3): Metronidazole 250 mg PO q6h for 7–14 days

PLA regimen

Alternative regimen (1): Proton pump inhibitor standard dose* PO q12h for 10 days AND
Alternative regimen (2): Levofloxacin 500mg PO q12h for 10 days AND
Alternative regimen (3): Amoxicillin 1g PO q12h for 10 days

PMA regimen

Alternative regimen (1): Proton pump inhibitor standard dose* PO q12h for 7–14 days AND
Alternative regimen (2): Metronidazole 250mg PO q6h for 7–14 days AND
Alternative regimen (3): Amoxicillin 1g PO q12h for 7–14 days

PRA regimen

Alternative regimen (1): Proton pump inhibitor standard dose* PO q12h for 10 days AND
Alternative regimen (2): Rifabutin 150–300mg PO q 24h for 10 days AND
Alternative regimen (3): Amoxicillin 1g PO q12h for 10 days

Bismuth quadruple therapy

Preferred regimen (1): Proton pump inhibitor standard dose* PO q12h for 10–14 days AND
Preferred regimen (2): Metronidazole 250mg PO q6h for 10–14 days AND
Preferred regimen (3): Tetracycline 500 mg PO q6hfor 10–14 days AND
Preferred regimen (4): Bismuth (dose depends on preparation) for 10–14 days

Bismuth-containing quadruple therapy

Bismuth quadruple therapy particularly advised in patients with any previous macrolide exposure or clarithromycin resistance is known to be high or who are allergic to penicillin ^[7]

Preferred regimen (1): Proton pump inhibitor standard dose* PO q12h for 10–14 days AND
Preferred regimen (2): Metronidazole 250mg PO q6h for 10–14 days AND
Preferred regimen (3): Tetracycline 500 mg PO q6h for 10–14 days AND
Preferred regimen (4): Bismuth (dose depends on preparation) for 10–14 days

Non–Bismuth-containing quadruple therapy

Concomitant therapy:^[8]^[9]

Preferred regimen (1): Proton pump inhibitor standard dose* PO q12h for 10–14 days AND
Preferred regimen (2): Clarithromycin 500mg PO q12h for 10–14 days AND
Preferred regimen (3): Amoxicillin 1g PO q12h for 10-14 days AND
Preferred regimen (4): Nitroimidazole 250mg PO q6h for 10–14 days

Sequential therapy:^[10]^[11]^[12]

Preferred regimen (1): Proton pump inhibitor standard dose* PO q12h for 5-7 days AND
Preferred regimen (2): Amoxicillin 1 g PO q12h for 5-7 days
FOLLOWED BY
Preferred regimen (1): Proton pump inhibitor standard dose* PO q12h for another 5-7days AND
Preferred regimen (2): Clarithromycin 500 mg PO q12h for another 5-7 days AND
Preferred regimen (3): Tinidazole 500 mg PO q12h for another 5-7 days

Hybrid therapy:

Preferred regimen (1): Proton pump inhibitor standard dose* PO q12h for 7 days
Preferred regimen (2): Amoxicillin 1g PO q12h for 7 days AND FOLLOWED BY

Preferred regimen (1): Proton pump inhibitor standard dose* PO q12h for 5-7 days AND
Preferred regimen (2): Amoxicillin 1g PO q12h for 7 days AND
Preferred regimen (3): Clarithromycin 500mg PO q12h for 7 days AND
Preferred regimen (4): Nitroimidazole 250mg PO q12h for 7 days

Levofloxacin triple therapy^[13]^[10]^[14]^[15]:

Preferred regimen (1): Proton pump inhibitor standard dose* PO q12h for 10-14 days AND
Preferred regimen (2): levofloxacin 500 mg PO q12h for 10–14 days AND
Preferred regimen (3): Amoxicillin 1g PO q12h for 10-14 days

Fluoroquinolone sequential therapy

Preferred regimen (1): Proton pump inhibitor standard dose PO q12h for 5 -7 days AND
Preferred regimen (2): Amoxicillin 1g PO q12h AND FOLLOWED BY
Preferred regimen (1): Proton pump inhibitor standard dose* PO q12h for 5–7 days AND
Preferred regimen (2): Fluoroquinolone 500mg PO q6h for 5–7 days AND
Preferred regimen (3): Nitroimidazole 250mg PO q6h for 5–7 days

*Standard dose of PPI: Lansoprazole 30 mg PO q12h, or Omeprazole 20 mg q12h, or Esomeprazole 40 mg PO q24h, or Rabeprazole 20 mg PO q12h

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.^[16]

Selection of a first-line H. pylori treatment regimen.

Is there a penicillin (PCN) allergy?
•Previous macrolide (MCL) exposure for any reason ?

•PCN allergy: No
•MCL exposure: No

•PCN allergy: No
•MCL exposure: Yes

•PCN allergy: Yes
•MCL exposure: No

•PCN allergy: Yes
•MCL exposure: Yes

Recomended treatment:
•Bismuth quadruple
•Clarithromycin triple with amoxicillin
Other options:
•Sequential
•HYBRID
•Levofloxacin triple
•Levofloxacin sequential
•LOAD

Recomended treatment:
•Bismuth quadruple
•Levofloxacin sequential
Other options:
•Concomitant therapy
•Sequential therapy
• HYBRID
•LOAD

Recommended treatment:
•Bismuth quadruple
•Clarithromycin triple
with metronidazole
•Bismuth quadruple

Recommended treatment:
•Bismuth quadruple
•Clarithromycin triple with metronidazole
•Bismuth quadruple

LOAD (Levofloxacin, Omeprazole, Alinia [nitazoxanide], and Doxycycline),

Recommended first-line therapies for H pylori infection: Adopted:American college of gasteroenterology^[17]

Regimen	Drug dose	Dosing frequency	Duration(days)	FDA approval
Clarithromycin triple	PPI standard or double dose PO Clarithromycin 500mg PO Amoxicillin 1gm PO or Metronidazole 500mg PO TID	BID	14 days	YES^†
Bismuth Quadruple	PPI standard dose PO Bismuth subcitrate 120-300mg or Subsalicylate 300mg PO Tetracyclin 500mg PO Metronidazole 250-500mg	BID QID QID TID to QID (500mg)	10-14 days	NO^‡
Concomitant	PPI standard dose PO Clarithromycin 500mg PO Amoxicillin 1gm PO Nitroimidazole 500mg^c	BID	10 -14 days	NO
Sequential	PPI standard dose +Amoxicillin 1gm PO PPI,Clarithromycin 500mg PO +Nitroimidazole 500mg ^c	BID BID	5-7 days 5-7 days	NO
Hybrid	PPI standard +Amoxicillin 1gm,PPI,Amoxicillin,Clarithromycin 500mg,Nitroimidazole 500mg^c	BID BID	7 days 7 days	NO
Levofloxacin triple	PPI standard dose PO Levofloxacin 500mg PO Amoxicillin 1gm PO	BID QID BID	10-14 days	NO
Levofloxacin sequential	PPI standard or double dose+Amoxicillin 1 gm PO PPI,Amoxicillin,Levofloxacin 500mg PO QD,Nitroimidazole 500mg^c	BID BID	5-7 days	NO
LOAD	Levofloxacin 250mg PO PPI double dose PO Nitazoxanide 500mg^c Doxycycline 100mg PO	QD QD BID QD	7-10 days	NO
	†: Several PPI, Clarithromycin, and Amoxicillin combinations have achieved FDA approval, PPI, Clarithromycin, Metronidazole are not an FDA approved treatment regimen. ‡: PPI, Bismuth, Tetracycline, and metronidazole prescribed separately are not an FDA approved treatment regimen. However, Pylera, a combination product containing Bismuth subcitrate, Tetracycline, Metronidazole combination with PPI for 10 days is an FDA approved regimen. BID, twice daily; FDA, Food and Drug Administration; PPI, proton pump inhibitor; TID, three times daily; QD, once daily; QID, four times daily. c: Metronidazole or Tinidazole^[1] *Adopted:American college of gasteroenterology^[17]

Persistent Helicobacter Pylori infection

With declining success rates for H. pylori eradication therapy, many patients will be persistently infected after treatment and will therefore remain at risk for the complications of H. pylori-related disease, such as peptic ulceration and gastric malignancy, testing to prove eradication should be performed using a urea breath test, fecal antigen test or biopsy-based testing at least 4 weeks after the completion of antibiotic therapy and after PPI therapy has been withheld for 1–2 weeks.In patients with persistent H. pylori infection, every effort should be made to avoid antibiotics that have been previously taken by the patient.^[1]^[18]

Persistent Helicobacter Pylori infection

Patient recieved clarithromycin triple therapy

Patient received Bismuth quadriple therapy

•No previous Quinolone exposure
•No PCN allergy
Recomended treatment:
•Bismuth quadruple
•Levofloxacin
•Rifabutin triple
•High dose dual

•Previous Quinolone exposure
•No PCN Allergy
Recomended treatment:
•Bismuth quadruple therapy
•Rifabutin triple
•High dose dual

•No previous Quinolone exposure
•PCN Allergy
Recomended treatment:
•Bismuth quadruple

•Previous Quinolone exposure
•PCN Allergy
Recomended treatment:
•Bismuth quadruple

•No previous Quinolone exposure
•No PCN allergy
Recomended treatment:
•Levofloxacin triple concomitant
•Rifabutin triple
•High dose triple

•Previous Quinolone exposure
•No PCN Allergy
Recomended treatment:
•Concomitant Rifabutin triple
•High dose dual

•No previous Quinolone
exposure
•PCN Allergy
Recomended treatment:
•PPI,Clarithromycin
,Metronidazole
•PPI,Levofloxacin,
Metronidazole

•Previous Quinolone exposure
•No PCN Allergy
Recomended treatment:
•PPI,Clarithromycin,
Metronidazole
•Bismuth quadruple

Adopted:American college of gasteroenterology[17]

Salvage treatment

After the failure of first-line therapy, such patients should be considered for referral for salvage treatment.

Salvage therapies for Helicobacter pylori infection
Regimen	Drugs(doses)	Dosing frequency	Duration(days)	FDA approval
Bismuth quadruple	PPI standard dose PO Bismuth subcitrate 120-300mg or sub salicylate 300mg Tetracycline 500mg	BID QID QID TID or QID	14	NO^(a)
Levofloxacin triple	PPI standard dose Levofloxacin 500mg Amoxicillin 1gm	BID QD BID	14	NO
Concomitant	PPI standard dose Clarithromycin 500mg Amoxicillin 1gm Nitroimidazole 500mg	BID BID BID BID or TID	10-14	NO
Rifabutin triple	PPI standard dose Rifabutin 300mg Amoxicillin 1gm	BID QD BID	10	NO
High-dose dual	PPI standard to double dose Amoxicillin 1gm TID or 750mg QID	TID or QID TID or QID	14	NO

(a)PPI,Bismuth,tetracyclin and metronidazole prescribed separately is not an FDA-approved treatment regimen.However,Pylera,a combination product containing bismuth subcitrate,tetracycline and metronidazole combined with a PPI for 10 days is an FDA-approved treatment regimen

BID, twice daily; FDA, Food and Drug Administration; PPI-proton pump inhibitor; TID-three times daily; QD-once daily; QID-four times daily^[1]

Adopted:American college of gasteroenterology[17]

Medical therapy for Non Helicobacter pylori-associated Peptic ulcer disease:

NSAIDs is most common cause of non-helicobacter pylori associated peptic ulcer disease
First step in management is to stop taking NSAIDs
Medical treatment for NSAIDs associated peptic ulcer :

H2- receptor Antagonist

Proton pump inhibitors

Omeprazole 20 mg
Lansoprazole 30 mg
Rabeprazole 20 mg
Pantoprazole 40 mg

Prevention of NSAID-induced ulcers
Drug	Dose
Misoprostol	200 μg q8h
Drug	Dose
Misoprostol	200 μg q8h
Proton pump inhibitors Omeprazole 20 mg Lansoprazole 30 mg Rabeprazole 20 mg Pantoprazole 40 mg	q 24 hourly

Treatment of ulcer according to stage of ulcer :

Active Ulcer
Drug	Dose
H2- receptor Antagonist Cimetidine 800 mg Ranitidine/nizatidine 300 mg Famotidine 40 mg	q 24 hourly(night)
Proton pump inhibitors Omeprazole 20 mg Lansoprazole 30 mg Rabeprazole 20 mg Pantoprazole 40 mg	q 24 hourly(empty stomach)
Maintenance therapy
H2-receptor antagonists Cimetidine 400 mg Ranitidine/nizatidine 150 mg Famotidine 20 mg	q 24 hourly(at night)
Proton pump inhibitors Omeprazole 20 mg Lansoprazole 30 mg Rabeprazole 20 mg Pantoprazole 40 mg	q 24 hourly (empty stomach)

Contraindicated Medications

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

Guidelines and Resources

American College of Gastroenterology (ACG) – Guidelines for the management of dyspepsia.^[19]
American Society for Gastrointestinal Endoscopy (ASGE) – The role of endoscopy in dyspepsia.^[20]
American Society for Gastrointestinal Endoscopy (ASGE) – The role of endoscopy in gastroduodenal obstruction and gastroparesis.^[21]
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.^[22]
The European Helicobacter Study Group (EHSG) – Management of Helicobacter pylori infection.^[23]

References

↑ ^1.0 ^1.1 ^1.2 ^1.3 "www.nature.com" (PDF).
↑ Federico A, Gravina AG, Miranda A, Loguercio C, Romano M (2014). "Eradication of Helicobacter pylori infection: which regimen first?". World J. Gastroenterol. 20 (3): 665–72. doi:10.3748/wjg.v20.i3.665. PMC 3921476. PMID 24574740.
↑ Zullo A, Rinaldi V, Winn S, Meddi P, Lionetti R, Hassan C, Ripani C, Tomaselli G, Attili AF (2000). "A new highly effective short-term therapy schedule for Helicobacter pylori eradication". Aliment. Pharmacol. Ther. 14 (6): 715–8. PMID 10848654.
↑ Maconi G, Parente F, Russo A, Vago L, Imbesi V, Bianchi Porro G (2001). "Do some patients with Helicobacter pylori infection benefit from an extension to 2 weeks of a proton pump inhibitor-based triple eradication therapy?". Am. J. Gastroenterol. 96 (2): 359–66. doi:10.1111/j.1572-0241.2001.03519.x. PMID 11232676.
↑ Fuccio L, Minardi ME, Zagari RM, Grilli D, Magrini N, Bazzoli F (2007). "Meta-analysis: duration of first-line proton-pump inhibitor based triple therapy for Helicobacter pylori eradication". Ann. Intern. Med. 147 (8): 553–62. PMID 17938394.
↑ Vakil N, Lanza F, Schwartz H, Barth J (2004). "Seven-day therapy for Helicobacter pylori in the United States". Aliment. Pharmacol. Ther. 20 (1): 99–107. doi:10.1111/j.1365-2036.2004.02029.x. PMID 15225176.
↑ Venerito M, Krieger T, Ecker T, Leandro G, Malfertheiner P (2013). Bismuthfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23880479 "Meta-analysis of bismuth quadruple therapy versus clarithromycin triple therapy for empiric primary treatment of Helicobacter pylori infection" Check |url= value (help). Digestion. 88 (1): 33–45. doi:10.1159/000350719. PMID 23880479.
↑ Wu DC, Hsu PI, Wu JY, Opekun AR, Kuo CH, Wu IC, Wang SS, Chen A, Hung WC, Graham DY (2010). "Sequential and concomitant therapy with four drugs is equally effective for eradication of H pylori infection". Clin. Gastroenterol. Hepatol. 8 (1): 36–41.e1. doi:10.1016/j.cgh.2009.09.030. PMC 2838430. PMID 19804842.
↑ Chuah SK, Tsay FW, Hsu PI, Wu DC (2011). "A new look at anti-Helicobacter pylori therapy". World J. Gastroenterol. 17 (35): 3971–5. doi:10.3748/wjg.v17.i35.3971. PMC 3199554. PMID 22046084.
↑ ^10.0 ^10.1 Gatta L, Vakil N, Leandro G, Di Mario F, Vaira D (2009). "Sequential therapy or triple therapy for Helicobacter pylori infection: systematic review and meta-analysis of randomized controlled trials in adults and children". Am. J. Gastroenterol. 104 (12): 3069–79, quiz 1080. doi:10.1038/ajg.2009.555. PMID 19844205.
↑ Vaira D, Zullo A, Vakil N, Gatta L, Ricci C, Perna F, Hassan C, Bernabucci V, Tampieri A, Morini S (2007). "Sequential therapy versus standard triple-drug therapy for Helicobacter pylori eradication: a randomized trial". Ann. Intern. Med. 146 (8): 556–63. PMID 17438314.
↑ Gisbert JP, Calvet X, O'Connor A, Mégraud F, O'Morain CA (2010). "Sequential therapy for Helicobacter pylori eradication: a critical review". J. Clin. Gastroenterol. 44 (5): 313–25. doi:10.1097/MCG.0b013e3181c8a1a3. PMID 20054285.
↑ Molina-Infante J, Perez-Gallardo B, Fernandez-Bermejo M, Hernandez-Alonso M, Vinagre G, Dueñas C, Mateos-Rodriguez JM, Gonzalez-Garcia G, Abadia EG, Gisbert JP (2010). "Clinical trial: clarithromycin vs. levofloxacin in first-line triple and sequential regimens for Helicobacter pylori eradication". Aliment. Pharmacol. Ther. 31 (10): 1077–84. doi:10.1111/j.1365-2036.2010.04274.x. PMID 20180787.
↑ Caselli M, Zullo A, Maconi G, Parente F, Alvisi V, Casetti T, Sorrentino D, Gasbarrini G (2007). ""Cervia II Working Group Report 2006": guidelines on diagnosis and treatment of Helicobacter pylori infection in Italy". Dig Liver Dis. 39 (8): 782–9. doi:10.1016/j.dld.2007.05.016. PMID 17606419.
↑ Romano M, Cuomo A, Gravina AG, Miranda A, Iovene MR, Tiso A, Sica M, Rocco A, Salerno R, Marmo R, Federico A, Nardone G (2010). "Empirical levofloxacin-containing versus clarithromycin-containing sequential therapy for Helicobacter pylori eradication: a randomised trial". Gut. 59 (11): 1465–70. doi:10.1136/gut.2010.215350. PMID 20947881.
↑ Malfertheiner, Peter; Megraud, Francis; O'Morain, Colm A.; Atherton, John; Axon, Anthony T. R.; Bazzoli, Franco; Gensini, Gian Franco; Gisbert, Javier P.; Graham, David Y.; Rokkas, Theodore; El-Omar, Emad M.; Kuipers, Ernst J.; European Helicobacter Study Group (2012-05). "Management of Helicobacter pylori infection--the Maastricht IV/ Florence Consensus Report". Gut. 61 (5): 646–664. doi:10.1136/gutjnl-2012-302084. ISSN 1468-3288. PMID 22491499. Check date values in: |date= (help)
↑ ^17.0 ^17.1 "Management of Patients with Ulcer Bleeding | American College of Gastroenterology".
↑ Chey WD, Wong BC (2007). "American College of Gastroenterology guideline on the management of Helicobacter pylori infection". Am. J. Gastroenterol. 102 (8): 1808–25. doi:10.1111/j.1572-0241.2007.01393.x. PMID 17608775.
↑ Talley, Nicholas J.; Vakil, Nimish; Practice Parameters Committee of the American College of Gastroenterology (2005-10). "Guidelines for the management of dyspepsia". The American Journal of Gastroenterology. 100 (10): 2324–2337. doi:10.1111/j.1572-0241.2005.00225.x. ISSN 0002-9270. PMID 16181387. Check date values in: |date= (help)
↑ Ikenberry, Steven O.; Harrison, M. Edwyn; Lichtenstein, David; Dominitz, Jason A.; Anderson, Michelle A.; Jagannath, Sanjay B.; Banerjee, Subhas; Cash, Brooks D.; Fanelli, Robert D.; Gan, Seng-Ian; Shen, Bo; Van Guilder, Trina; Lee, Kenneth K.; Baron, Todd H.; ASGE STANDARDS OF PRACTICE COMMITTEE (2007-12). "The role of endoscopy in dyspepsia". Gastrointestinal Endoscopy. 66 (6): 1071–1075. doi:10.1016/j.gie.2007.07.007. ISSN 0016-5107. PMID 18028927. Check date values in: |date= (help)
↑ ASGE Standards of Practice Committee; Fukami, Norio; Anderson, Michelle A.; Khan, Khalid; Harrison, M. Edwyn; Appalaneni, Vasudhara; Ben-Menachem, Tamir; Decker, G. Anton; Fanelli, Robert D.; Fisher, Laurel; Ikenberry, Steven O.; Jain, Rajeev; Jue, Terry L.; Krinsky, Mary Lee; Maple, John T.; Sharaf, Ravi N.; Dominitz, Jason A. (2011-07). "The role of endoscopy in gastroduodenal obstruction and gastroparesis". Gastrointestinal Endoscopy. 74 (1): 13–21. doi:10.1016/j.gie.2010.12.003. ISSN 1097-6779. PMID 21704805. Check date values in: |date= (help)
↑ Bhatt, Deepak L.; Scheiman, James; Abraham, Neena S.; Antman, Elliott M.; Chan, Francis K. L.; Furberg, Curt D.; Johnson, David A.; Mahaffey, Kenneth W.; Quigley, Eamonn M.; American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents (2008-10-28). "ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents". Circulation. 118 (18): 1894–1909. doi:10.1161/CIRCULATIONAHA.108.191087. ISSN 1524-4539. PMID 18836135.
↑ Malfertheiner, Peter; Megraud, Francis; O'Morain, Colm A.; Atherton, John; Axon, Anthony T. R.; Bazzoli, Franco; Gensini, Gian Franco; Gisbert, Javier P.; Graham, David Y.; Rokkas, Theodore; El-Omar, Emad M.; Kuipers, Ernst J.; European Helicobacter Study Group (2012-05). "Management of Helicobacter pylori infection--the Maastricht IV/ Florence Consensus Report". Gut. 61 (5): 646–664. doi:10.1136/gutjnl-2012-302084. ISSN 1468-3288. PMID 22491499. Check date values in: |date= (help)

[urlwww.nature.com-1] 1.0 ^1.1 ^1.2 ^1.3 "www.nature.com" (PDF).

[pmid24574740-2] Federico A, Gravina AG, Miranda A, Loguercio C, Romano M (2014). "Eradication of Helicobacter pylori infection: which regimen first?". World J. Gastroenterol. 20 (3): 665–72. doi:10.3748/wjg.v20.i3.665. PMC 3921476. PMID 24574740.

[pmid10848654-3] Zullo A, Rinaldi V, Winn S, Meddi P, Lionetti R, Hassan C, Ripani C, Tomaselli G, Attili AF (2000). "A new highly effective short-term therapy schedule for Helicobacter pylori eradication". Aliment. Pharmacol. Ther. 14 (6): 715–8. PMID 10848654.

[pmid11232676-4] Maconi G, Parente F, Russo A, Vago L, Imbesi V, Bianchi Porro G (2001). "Do some patients with Helicobacter pylori infection benefit from an extension to 2 weeks of a proton pump inhibitor-based triple eradication therapy?". Am. J. Gastroenterol. 96 (2): 359–66. doi:10.1111/j.1572-0241.2001.03519.x. PMID 11232676.

[pmid17938394-5] Fuccio L, Minardi ME, Zagari RM, Grilli D, Magrini N, Bazzoli F (2007). "Meta-analysis: duration of first-line proton-pump inhibitor based triple therapy for Helicobacter pylori eradication". Ann. Intern. Med. 147 (8): 553–62. PMID 17938394.

[pmid15225176-6] Vakil N, Lanza F, Schwartz H, Barth J (2004). "Seven-day therapy for Helicobacter pylori in the United States". Aliment. Pharmacol. Ther. 20 (1): 99–107. doi:10.1111/j.1365-2036.2004.02029.x. PMID 15225176.

[pmid23880479-7] Venerito M, Krieger T, Ecker T, Leandro G, Malfertheiner P (2013). Bismuthfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23880479 "Meta-analysis of bismuth quadruple therapy versus clarithromycin triple therapy for empiric primary treatment of Helicobacter pylori infection" Check |url= value (help). Digestion. 88 (1): 33–45. doi:10.1159/000350719. PMID 23880479.

[pmid19804842-8] Wu DC, Hsu PI, Wu JY, Opekun AR, Kuo CH, Wu IC, Wang SS, Chen A, Hung WC, Graham DY (2010). "Sequential and concomitant therapy with four drugs is equally effective for eradication of H pylori infection". Clin. Gastroenterol. Hepatol. 8 (1): 36–41.e1. doi:10.1016/j.cgh.2009.09.030. PMC 2838430. PMID 19804842.

[pmid22046084-9] Chuah SK, Tsay FW, Hsu PI, Wu DC (2011). "A new look at anti-Helicobacter pylori therapy". World J. Gastroenterol. 17 (35): 3971–5. doi:10.3748/wjg.v17.i35.3971. PMC 3199554. PMID 22046084.

[pmid19844205-10] 10.0 ^10.1 Gatta L, Vakil N, Leandro G, Di Mario F, Vaira D (2009). "Sequential therapy or triple therapy for Helicobacter pylori infection: systematic review and meta-analysis of randomized controlled trials in adults and children". Am. J. Gastroenterol. 104 (12): 3069–79, quiz 1080. doi:10.1038/ajg.2009.555. PMID 19844205.

[pmid17438314-11] Vaira D, Zullo A, Vakil N, Gatta L, Ricci C, Perna F, Hassan C, Bernabucci V, Tampieri A, Morini S (2007). "Sequential therapy versus standard triple-drug therapy for Helicobacter pylori eradication: a randomized trial". Ann. Intern. Med. 146 (8): 556–63. PMID 17438314.

[pmid20054285-12] Gisbert JP, Calvet X, O'Connor A, Mégraud F, O'Morain CA (2010). "Sequential therapy for Helicobacter pylori eradication: a critical review". J. Clin. Gastroenterol. 44 (5): 313–25. doi:10.1097/MCG.0b013e3181c8a1a3. PMID 20054285.

[pmid20180787-13] Molina-Infante J, Perez-Gallardo B, Fernandez-Bermejo M, Hernandez-Alonso M, Vinagre G, Dueñas C, Mateos-Rodriguez JM, Gonzalez-Garcia G, Abadia EG, Gisbert JP (2010). "Clinical trial: clarithromycin vs. levofloxacin in first-line triple and sequential regimens for Helicobacter pylori eradication". Aliment. Pharmacol. Ther. 31 (10): 1077–84. doi:10.1111/j.1365-2036.2010.04274.x. PMID 20180787.

[pmid17606419-14] Caselli M, Zullo A, Maconi G, Parente F, Alvisi V, Casetti T, Sorrentino D, Gasbarrini G (2007). ""Cervia II Working Group Report 2006": guidelines on diagnosis and treatment of Helicobacter pylori infection in Italy". Dig Liver Dis. 39 (8): 782–9. doi:10.1016/j.dld.2007.05.016. PMID 17606419.

[pmid20947881-15] Romano M, Cuomo A, Gravina AG, Miranda A, Iovene MR, Tiso A, Sica M, Rocco A, Salerno R, Marmo R, Federico A, Nardone G (2010). "Empirical levofloxacin-containing versus clarithromycin-containing sequential therapy for Helicobacter pylori eradication: a randomised trial". Gut. 59 (11): 1465–70. doi:10.1136/gut.2010.215350. PMID 20947881.

[16] Malfertheiner, Peter; Megraud, Francis; O'Morain, Colm A.; Atherton, John; Axon, Anthony T. R.; Bazzoli, Franco; Gensini, Gian Franco; Gisbert, Javier P.; Graham, David Y.; Rokkas, Theodore; El-Omar, Emad M.; Kuipers, Ernst J.; European Helicobacter Study Group (2012-05). "Management of Helicobacter pylori infection--the Maastricht IV/ Florence Consensus Report". Gut. 61 (5): 646–664. doi:10.1136/gutjnl-2012-302084. ISSN 1468-3288. PMID 22491499. Check date values in: |date= (help)

[urlManagement_of_Patients_with_Ulcer_Bleeding_|_American_College_of_Gastroenterology-17] 17.0 ^17.1 "Management of Patients with Ulcer Bleeding | American College of Gastroenterology".

[pmid17608775-18] Chey WD, Wong BC (2007). "American College of Gastroenterology guideline on the management of Helicobacter pylori infection". Am. J. Gastroenterol. 102 (8): 1808–25. doi:10.1111/j.1572-0241.2007.01393.x. PMID 17608775.

[19] Talley, Nicholas J.; Vakil, Nimish; Practice Parameters Committee of the American College of Gastroenterology (2005-10). "Guidelines for the management of dyspepsia". The American Journal of Gastroenterology. 100 (10): 2324–2337. doi:10.1111/j.1572-0241.2005.00225.x. ISSN 0002-9270. PMID 16181387. Check date values in: |date= (help)

[20] Ikenberry, Steven O.; Harrison, M. Edwyn; Lichtenstein, David; Dominitz, Jason A.; Anderson, Michelle A.; Jagannath, Sanjay B.; Banerjee, Subhas; Cash, Brooks D.; Fanelli, Robert D.; Gan, Seng-Ian; Shen, Bo; Van Guilder, Trina; Lee, Kenneth K.; Baron, Todd H.; ASGE STANDARDS OF PRACTICE COMMITTEE (2007-12). "The role of endoscopy in dyspepsia". Gastrointestinal Endoscopy. 66 (6): 1071–1075. doi:10.1016/j.gie.2007.07.007. ISSN 0016-5107. PMID 18028927. Check date values in: |date= (help)

[21] ASGE Standards of Practice Committee; Fukami, Norio; Anderson, Michelle A.; Khan, Khalid; Harrison, M. Edwyn; Appalaneni, Vasudhara; Ben-Menachem, Tamir; Decker, G. Anton; Fanelli, Robert D.; Fisher, Laurel; Ikenberry, Steven O.; Jain, Rajeev; Jue, Terry L.; Krinsky, Mary Lee; Maple, John T.; Sharaf, Ravi N.; Dominitz, Jason A. (2011-07). "The role of endoscopy in gastroduodenal obstruction and gastroparesis". Gastrointestinal Endoscopy. 74 (1): 13–21. doi:10.1016/j.gie.2010.12.003. ISSN 1097-6779. PMID 21704805. Check date values in: |date= (help)

[22] Bhatt, Deepak L.; Scheiman, James; Abraham, Neena S.; Antman, Elliott M.; Chan, Francis K. L.; Furberg, Curt D.; Johnson, David A.; Mahaffey, Kenneth W.; Quigley, Eamonn M.; American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents (2008-10-28). "ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents". Circulation. 118 (18): 1894–1909. doi:10.1161/CIRCULATIONAHA.108.191087. ISSN 1524-4539. PMID 18836135.

[23] Malfertheiner, Peter; Megraud, Francis; O'Morain, Colm A.; Atherton, John; Axon, Anthony T. R.; Bazzoli, Franco; Gensini, Gian Franco; Gisbert, Javier P.; Graham, David Y.; Rokkas, Theodore; El-Omar, Emad M.; Kuipers, Ernst J.; European Helicobacter Study Group (2012-05). "Management of Helicobacter pylori infection--the Maastricht IV/ Florence Consensus Report". Gut. 61 (5): 646–664. doi:10.1136/gutjnl-2012-302084. ISSN 1468-3288. PMID 22491499. Check date values in: |date= (help)

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@@ Line 1: / Line 1: @@
-__NOTOC____NOEDITSECTION__
+__NOTOC__
 {{Peptic ulcer}}
-{{CMG}}; Gerald Chi, M.D.
+{{CMG}} ; {{AE}} {{MKK}}
 ==Overview==
-Eradication of ''[[Helicobacter pylori]]'' with antimicrobial agents is indicated for patients with [[gastric ulcer|gastric]] or [[duodenal ulcer|duodenal peptic ulceration]] who are colonized with ''[[Helicobacter pylori]]'' and patients with [[MALT lymphoma]].  Eradication therapy should also be considered for patients with [[immune thrombocytopenic purpura]] who are ''[[H. pylori]]'' positive or patients who have undergone resection for early-stage [[gastric cancer]].  The use of antibiotics is discouraged in asymptomatic carriers.
+The mainstay of treatment for peptic ulcer disease is pharmacotherapy. Treatment of ''[[Helicobacter pylori]]'' with antimicrobial agents is indicated for patients with [[gastric ulcer|gastric]] or [[duodenal]] [[ulceration]].  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. After the first line therapy, patient is tested for persistent H.pylori infection. If the patient has persistent infection, treatment is planned according to previous [[antibiotics]] therapy. Salvage treatment is used for failure of first line therapy. The use of antimicrobial therapy is discouraged among asymptomatic carriers.
 ==Medical Therapy==
-{| style="float: right; width: 300px; margin: 5px 10px;"
+The mainstay of treatment for peptic ulcer disease is pharmacotherapy. Pharmacotherapy for peptic ulcer disease can be discussed under [[Helicobacter pylori]]-associated peptic ulcer and  Non- [[Helicobacter pylori]]-associated [[peptic ulcer]] disease.
-! style="font-size: 85%; background: #545454; color: #F8F8FF; padding: 5px 10px;" | Countries with a reported prevalence < 15% of ''H. pylori'' resistance to clarithromycin
+===Eradication Therapy for ''Helicobacter pylori'' Infection===
+The ACG’s 2017 treatment guideline on the management of [[H. pylori]] infection listed the following as established indications for diagnosis and treatment:<ref name="urlwww.nature.com">{{cite web |url=https://www.nature.com/ajg/journal/v112/n2/pdf/ajg2016563a.pdf |title=www.nature.com |format= |work= |accessdate=}}</ref>
+====Indications====
+*Active [[Peptic ulcer]] disease ([[gastric]] or [[duodenal]]).
+*Confirmed history of PUD (not previously treated for [[H. pylori]])
+*[[Gastric]] [[MALT lymphoma]] (low grade)
+*After [[endoscopic]] resection of [[gastric cancer]]
+'''Depending upon exposure of antibiotics and allergy to antibiotics, following treatments regimen are being used''':<ref name="pmid24574740">{{cite journal |vauthors=Federico A, Gravina AG, Miranda A, Loguercio C, Romano M |title=Eradication of Helicobacter pylori infection: which regimen first? |journal=World J. Gastroenterol. |volume=20 |issue=3 |pages=665–72 |year=2014 |pmid=24574740 |pmc=3921476 |doi=10.3748/wjg.v20.i3.665 |url=}}</ref><ref name="pmid10848654">{{cite journal |vauthors=Zullo A, Rinaldi V, Winn S, Meddi P, Lionetti R, Hassan C, Ripani C, Tomaselli G, Attili AF |title=A new highly effective short-term therapy schedule for Helicobacter pylori eradication |journal=Aliment. Pharmacol. Ther. |volume=14 |issue=6 |pages=715–8 |year=2000 |pmid=10848654 |doi= |url=}}</ref>
+====Triple Therapy====
+*Triple  therapy consisting of a [[Proton pump inhibitors]] and 2 [[antibiotics]]  for 14 days remains a recommended [[treatment]] in regions where [[H. pylori]] [[clarithromycin]] resistance is known to be <15% and in patients with no previous history of [[macrolide]] exposure.<ref name="pmid11232676">{{cite journal |vauthors=Maconi G, Parente F, Russo A, Vago L, Imbesi V, Bianchi Porro G |title=Do some patients with Helicobacter pylori infection benefit from an extension to 2 weeks of a proton pump inhibitor-based triple eradication therapy? |journal=Am. J. Gastroenterol. |volume=96 |issue=2 |pages=359–66 |year=2001 |pmid=11232676 |doi=10.1111/j.1572-0241.2001.03519.x |url=}}</ref><ref name="pmid17938394">{{cite journal |vauthors=Fuccio L, Minardi ME, Zagari RM, Grilli D, Magrini N, Bazzoli F |title=Meta-analysis: duration of first-line proton-pump inhibitor based triple therapy for Helicobacter pylori eradication |journal=Ann. Intern. Med. |volume=147 |issue=8 |pages=553–62 |year=2007 |pmid=17938394 |doi= |url=}}</ref><ref name="pmid15225176">{{cite journal |vauthors=Vakil N, Lanza F, Schwartz H, Barth J |title=Seven-day therapy for Helicobacter pylori in the United States |journal=Aliment. Pharmacol. Ther. |volume=20 |issue=1 |pages=99–107 |year=2004 |pmid=15225176 |doi=10.1111/j.1365-2036.2004.02029.x |url=}}</ref>
+* '''<u>PCA regimen</u>'''
+:* Preferred regimen (1):'''[[Proton pump inhibitor|P]]'''[[Proton pump inhibitor|roton pump inhibitor]] standard dose* PO q12h for 7–14 days {{and}}
+:* Preferred regimen (2):[[Clarithromycin]] 500 mg PO q12h for 7–14 days {{and}}
+:* Preferred regimen (3):[[Amoxicillin]] 1 g PO q12h for 7–14 days {{or}} [[Metronidazole]] 250 mg PO q6h for 7–14 days
+* <u>'''PCM regimen'''</u>
+:*Alternative regimen (1): [[Proton pump inhibitor]] standard dose* PO q12h  for 7–14 days {{and}}
+:*Alternative regimen (2): [[Clarithromycin]] 500 mg PO  q12h for 7–14 days {{and}}
+:*Alternative regimen (3): [[Metronidazole]] 250 mg PO q6h for 7–14 days
+* '''<u>PLA regimen</u>'''
+:*Alternative regimen (1): [[Proton pump inhibitor]] standard dose* PO q12h for 10 days {{and}}
+:*Alternative regimen (2): [[Levofloxacin]] 500mg PO q12h for 10 days {{and}}
+:*Alternative regimen (3): [[Amoxicillin]] 1g PO q12h for 10 days
+* '''<u>PMA regimen</u>'''
+:*Alternative regimen (1): [[Proton pump inhibitor]] standard dose* PO q12h for 7–14 days {{and}}
+:*Alternative regimen (2): [[Metronidazole]] 250mg PO q6h for 7–14 days {{and}}
+:*Alternative regimen (3): [[Amoxicillin]] 1g PO q12h for 7–14 days
+* '''<u>PRA regimen</u>'''
+:*Alternative regimen (1): [[Proton pump inhibitor]] standard dose* PO q12h for 10 days {{and}}
+:*Alternative regimen (2): [[Rifabutin]] 150–300mg PO q 24h for 10 days {{and}}
+:*Alternative regimen (3): [[Amoxicillin]] 1g PO q12h for 10 days
+* '''Bismuth quadruple therapy'''
+:*Preferred regimen (1): [[Proton pump inhibitor]] standard dose* PO q12h for 10–14 days {{and}}
+:*Preferred regimen (2): [[Metronidazole]] 250mg PO q6h for 10–14 days {{and}}
+:*Preferred regimen (3): [[Tetracycline]] 500 mg PO q6hfor 10–14 days {{and}}
+:*Preferred regimen (4): [[Bismuth]] (dose depends on preparation) for 10–14 days
+====Bismuth-containing quadruple therapy====
+*Bismuth quadruple therapy particularly advised in patients with any previous macrolide exposure or clarithromycin resistance is known to be high or who are allergic to penicillin <ref name="pmid23880479">{{cite journal| author=Venerito M, Krieger T, Ecker T, Leandro G, Malfertheiner P| title=Meta-analysis of bismuth quadruple therapy versus clarithromycin triple therapy for empiric primary treatment of Helicobacter pylori infection. | journal=Digestion | year= 2013 | volume= 88 | issue= 1 | pages= 33-45 | pmid=23880479 | doi=10.1159/000350719 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?d.* Bismuthfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23880479  }} </ref>
+:*Preferred regimen (1): [[Proton pump inhibitor]] standard dose* PO q12h for 10–14 days {{and}}
+:*Preferred regimen (2): [[Metronidazole]] 250mg PO q6h  for 10–14 days {{and}}
+:*Preferred regimen (3): [[Tetracycline]] 500 mg PO q6h for 10–14 days {{and}}
+:*Preferred regimen (4): [[Bismuth]] (dose depends on preparation) for 10–14 days
+====Non–Bismuth-containing quadruple therapy====
+* '''Concomitant therapy:'''<ref name="pmid19804842">{{cite journal |vauthors=Wu DC, Hsu PI, Wu JY, Opekun AR, Kuo CH, Wu IC, Wang SS, Chen A, Hung WC, Graham DY |title=Sequential and concomitant therapy with four drugs is equally effective for eradication of H pylori infection |journal=Clin. Gastroenterol. Hepatol. |volume=8 |issue=1 |pages=36–41.e1 |year=2010 |pmid=19804842 |pmc=2838430 |doi=10.1016/j.cgh.2009.09.030 |url=}}</ref><ref name="pmid22046084">{{cite journal |vauthors=Chuah SK, Tsay FW, Hsu PI, Wu DC |title=A new look at anti-Helicobacter pylori therapy |journal=World J. Gastroenterol. |volume=17 |issue=35 |pages=3971–5 |year=2011 |pmid=22046084 |pmc=3199554 |doi=10.3748/wjg.v17.i35.3971 |url=}}</ref>
+:*Preferred regimen (1): [[Proton pump inhibitor]] standard dose* PO q12h for 10–14 days {{and}}
+:*Preferred regimen (2): [[Clarithromycin]] 500mg PO  q12h  for 10–14 days {{and}}
+:*Preferred regimen (3): [[Amoxicillin]] 1g PO q12h   for 10-14 days {{and}}
+:*Preferred regimen (4): [[Nitroimidazole ]] 250mg PO q6h  for 10–14 days
+* '''Sequential therapy:'''<ref name="pmid19844205">{{cite journal |vauthors=Gatta L, Vakil N, Leandro G, Di Mario F, Vaira D |title=Sequential therapy or triple therapy for Helicobacter pylori infection: systematic review and meta-analysis of randomized controlled trials in adults and children |journal=Am. J. Gastroenterol. |volume=104 |issue=12 |pages=3069–79; quiz 1080 |year=2009 |pmid=19844205 |doi=10.1038/ajg.2009.555 |url=}}</ref><ref name="pmid17438314">{{cite journal |vauthors=Vaira D, Zullo A, Vakil N, Gatta L, Ricci C, Perna F, Hassan C, Bernabucci V, Tampieri A, Morini S |title=Sequential therapy versus standard triple-drug therapy for Helicobacter pylori eradication: a randomized trial |journal=Ann. Intern. Med. |volume=146 |issue=8 |pages=556–63 |year=2007 |pmid=17438314 |doi= |url=}}</ref><ref name="pmid20054285">{{cite journal |vauthors=Gisbert JP, Calvet X, O'Connor A, Mégraud F, O'Morain CA |title=Sequential therapy for Helicobacter pylori eradication: a critical review |journal=J. Clin. Gastroenterol. |volume=44 |issue=5 |pages=313–25 |year=2010 |pmid=20054285 |doi=10.1097/MCG.0b013e3181c8a1a3 |url=}}</ref>
+:*Preferred regimen (1): [[Proton pump inhibitor|Proton pump inhibito'''r''']] standard dose* PO q12h  for 5-7 days {{and}}
+:*Preferred regimen (2): [[Amoxicillin]] 1 g PO q12h for 5-7 days<BR><span style="text-indent: 50px;">'''<u>FOLLOWED BY</u>'''</span>
+:*Preferred regimen (1): [[Proton pump inhibitor]] standard dose* PO  q12h for another 5-7days {{and}}
+:*Preferred regimen (2): [[Clarithromycin]] 500 mg PO q12h for another 5-7 days {{and}}
+:*Preferred regimen (3): [[Tinidazole]] 500 mg  PO q12h  for another 5-7 days
+'''Hybrid therapy''':
+:*Preferred regimen (1): [[Proton pump inhibitor]] standard dose* PO q12h for 7 days
+:*Preferred regimen (2): [[Amoxicillin]] 1g PO q12h for 7 days '''<u>AND</u>'''  <u>'''FOLLOWED BY'''</u>
+:*Preferred regimen (1): [[Proton pump inhibitor]] standard dose* PO  q12h for 5-7 days '''<u>AND</u>'''
+:*Preferred regimen (2): [[Amoxicillin]] 1g PO q12h for 7 days '''<u>AND</u>'''
+:*Preferred regimen (3): [[Clarithromycin]] 500mg PO  q12h for 7 days '''<u>AND</u>'''
+:*Preferred regimen (4): [[Nitroimidazole |Nitroimidazol'''e ''']] 250mg PO q12h for 7 days
+*'''Levofloxacin triple therapy'''<ref name="pmid20180787">{{cite journal |vauthors=Molina-Infante J, Perez-Gallardo B, Fernandez-Bermejo M, Hernandez-Alonso M, Vinagre G, Dueñas C, Mateos-Rodriguez JM, Gonzalez-Garcia G, Abadia EG, Gisbert JP |title=Clinical trial: clarithromycin vs. levofloxacin in first-line triple and sequential regimens for Helicobacter pylori eradication |journal=Aliment. Pharmacol. Ther. |volume=31 |issue=10 |pages=1077–84 |year=2010 |pmid=20180787 |doi=10.1111/j.1365-2036.2010.04274.x |url=}}</ref><ref name="pmid19844205">{{cite journal |vauthors=Gatta L, Vakil N, Leandro G, Di Mario F, Vaira D |title=Sequential therapy or triple therapy for Helicobacter pylori infection: systematic review and meta-analysis of randomized controlled trials in adults and children |journal=Am. J. Gastroenterol. |volume=104 |issue=12 |pages=3069–79; quiz 1080 |year=2009 |pmid=19844205 |doi=10.1038/ajg.2009.555 |url=}}</ref><ref name="pmid17606419">{{cite journal |vauthors=Caselli M, Zullo A, Maconi G, Parente F, Alvisi V, Casetti T, Sorrentino D, Gasbarrini G |title="Cervia II Working Group Report 2006": guidelines on diagnosis and treatment of Helicobacter pylori infection in Italy |journal=Dig Liver Dis |volume=39 |issue=8 |pages=782–9 |year=2007 |pmid=17606419 |doi=10.1016/j.dld.2007.05.016 |url=}}</ref><ref name="pmid20947881">{{cite journal |vauthors=Romano M, Cuomo A, Gravina AG, Miranda A, Iovene MR, Tiso A, Sica M, Rocco A, Salerno R, Marmo R, Federico A, Nardone G |title=Empirical levofloxacin-containing versus clarithromycin-containing sequential therapy for Helicobacter pylori eradication: a randomised trial |journal=Gut |volume=59 |issue=11 |pages=1465–70 |year=2010 |pmid=20947881 |doi=10.1136/gut.2010.215350 |url=}}</ref>:
+:*Preferred regimen (1): [[Proton pump inhibitor]] standard dose* PO q12h  for 10-14 days '''<u>AND</u>'''
+:*Preferred regimen (2): [[levofloxacin|'''l'''evofloxacin]] 500 mg  PO q12h  for 10–14 days '''<u>AND</u>'''
+:*Preferred regimen (3): [[Amoxicillin]] 1g  PO q12h   for 10-14 days
+*'''Fluoroquinolone sequential therapy'''
+:*Preferred regimen (1): [[Proton pump inhibitor]] standard dose PO q12h for 5 -7 days '''<u>AND</u>'''
+:*Preferred regimen (2): [[Amoxicillin]] 1g PO q12h '''<u>AND</u>'''     <u>'''FOLLOWED'''</u> '''<u>BY</u>'''
+:*Preferred regimen (1): [[Proton pump inhibitor]] standard dose* PO q12h for 5–7 days '''<u>AND</u>'''
+:*Preferred regimen (2): [[Fluoroquinolone]] 500mg PO q6h for 5–7 days '''<u>AND</u>'''
+:*Preferred regimen (3): [[Nitroimidazole]] 250mg PO q6h for  5–7 days
+<nowiki>*</nowiki>Standard dose of PPI: [[Lansoprazole]] 30 mg PO q12h, or [[Omeprazole]] 20 mg q12h, or [[Esomeprazole]] 40 mg PO q24h, or [[Rabeprazole]] 20 mg PO q12h
+* 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.<ref>{{Cite journal| doi = 10.1136/gutjnl-2012-302084| issn = 1468-3288| volume = 61| issue = 5| pages = 646–664| last1 = Malfertheiner| first1 = Peter| last2 = Megraud| first2 = Francis| last3 = O'Morain| first3 = Colm A.| last4 = Atherton| first4 = John| last5 = Axon| first5 = Anthony T. R.| last6 = Bazzoli| first6 = Franco| last7 = Gensini| first7 = Gian Franco| last8 = Gisbert| first8 = Javier P.| last9 = Graham| first9 = David Y.| last10 = Rokkas| first10 = Theodore| last11 = El-Omar| first11 = Emad M.| last12 = Kuipers| first12 = Ernst J.| last13 = European Helicobacter Study Group| title = Management of Helicobacter pylori infection--the Maastricht IV/ Florence Consensus Report| journal = Gut| date = 2012-05| pmid = 22491499}}</ref>
+'''Selection of a first-line H. pylori treatment regimen.'''<br><br>
+{{familytree/start}}
+{{familytree |boxstyle=text-align: left; | | | | | | | | | A01 | | | |A01= Is there a penicillin (PCN) allergy?<br> •Previous [[macrolide]] (MCL) exposure for any reason ?<br>}}
+{{familytree | | |,|-|-|-|-|v|-|^|-|v|-|-|-|.| ||}}
+{{familytree |boxstyle=text-align: left; | | B01 | | | B02 | | B03 | | B04||B01=•PCN allergy: '''No'''<br> •MCL exposure: '''No'''<br> |B02=•PCN allergy: '''No'''<br> •MCL exposure: '''Yes'''<br> |B03=•PCN allergy: '''Yes'''<br> •MCL exposure: '''No'''<br> |B04=•PCN allergy: '''Yes'''<br> •MCL exposure: '''Yes'''<br> }}
+{{familytree | | |!| | | | |!| | | |!| | | |!| ||}}
+{{familytree |boxstyle=text-align: left; | | B01 | | | B02 | | B03 | | B04||B01='''Recomended treatment:'''<br> •[[Bismuth]] quadruple <br> •[[Clarithromycin]] triple with [[amoxicillin]]<br> '''Other options''':<br> •Sequential<br> •HYBRID<br> •[[Levofloxacin]] triple<br> •[[Levofloxacin]] sequential <br>•LOAD<br> |B02='''Recomended treatment:'''<br>•[[Bismuth]] quadruple <br>•[[Levofloxacin]] sequential<br>'''Other options''':<br>•Concomitant therapy<br>•Sequential therapy <br>• HYBRID<br> •LOAD<br>|B03='''Recommended treatment:'''<br> •[[Bismuth]] quadruple <br> •[[Clarithromycin]] triple <br> with [[metronidazole]]<br> •[[Bismuth]] quadruple<br>|B04= '''Recommended treatment:''' <br> •[[Bismuth]] quadruple <br> •[[Clarithromycin]] triple with [[metronidazole]]<br> •[[Bismuth]] quadruple<br>}}
+{{Familytree/end}}
+'''LOAD''' (Levofloxacin, Omeprazole, Alinia [nitazoxanide], and Doxycycline),
+'''Recommended first-line therapies for H pylori infection''':
+<small>Adopted:American college of gasteroenterology<ref name="urlManagement of Patients with Ulcer Bleeding | American College of Gastroenterology" /> </small>
+{| class="wikitable"
+!Regimen
+!Drug dose
+!Dosing frequency
+!Duration(days)
+!FDA approval
 |-
-! style="font-size: 85%; background: #DCDCDC;" | Europe
+|[[Clarithromycin]] triple
+|[[PPI]] standard or double dose PO
+[[Clarithromycin]] 500mg PO
+[[Amoxicillin]] 1gm PO or [[Metronidazole]] 500mg PO TID
+|BID
+|14 days
+|YES<sup>'''†'''</sup>
 |-
-| style="font-size: 85%; background: #F5F5F5;" |
+|[[Bismuth]] Quadruple
-* Belgium (3%)
+|[[PPI]]  standard dose PO
-* Croatia (8.2%)
+[[Bismuth]] subcitrate 120-300mg or Subsalicylate 300mg PO
-* Denmark (11%)
-* Finland (2%)
+[[Tetracyclin]]  500mg PO
-* Germany (2.2–4%)
-* Italy (North) (1.8%)
+[[Metronidazole]] 250-500mg
-* Ireland (8.8%)
+|BID
-* Netherlands (1.7%)
+QID
-* Sweden (2.9%)
-* UK (8.3–12.7%)
+QID
+TID to QID (500mg)
+|10-14 days
+|NO<sup>'''‡'''</sup>
 |-
-! style="font-size: 85%; background: #DCDCDC;" | North America
+|Concomitant
+|[[PPI]] standard dose PO
+[[Clarithromycin]] 500mg PO
+[[Amoxicillin]] 1gm PO
+[[Nitroimidazole]] 500mg<sup>c</sup>
+|BID
+|10 -14 days
+|NO
 |-
-| style="font-size: 85%; background: #F5F5F5;" |
+|Sequential
-* Canada (12%)
+|[[PPI]] standard dose +[[Amoxicillin]] 1gm PO
-* USA (10.6–12.2%)
+[[PPI]],[[Clarithromycin]] 500mg PO +[[Nitroimidazole]] 500mg <sup>c</sup>
+|BID
+BID
+|5-7 days
+-7 days
+|NO
 |-
-! style="font-size: 85%; background: #DCDCDC;" | South America
+|Hybrid
+|[[PPI]] standard +[[Amoxicillin]] 1gm,[[PPI]],[[Amoxicillin]],[[Clarithromycin]] 500mg,[[Nitroimidazole]] 500mg<sup>c</sup>
+|BID
+BID
+|7 days
+days
+|NO
 |-
-| style="font-size: 85%; background: #F5F5F5;" |
+|[[Levofloxacin]] triple
-* Brazil (9.8%)
+|[[PPI]] standard dose PO
+[[Levofloxacin]] 500mg PO
+[[Amoxicillin]] 1gm PO
+|BID
+QID
+BID
+|10-14 days
+|NO
 |-
-! style="font-size: 85%; background: #DCDCDC;" | Middle East
+|[[Levofloxacin]] sequential
+|[[PPI]] standard or double dose+[[Amoxicillin]] 1 gm PO
+[[PPI]],[[Amoxicillin]],[[Levofloxacin]] 500mg  PO QD,[[Nitroimidazole]] 500mg<sup>c</sup>
+|BID
+BID
+|5-7 days
+|NO
 |-
-| style="font-size: 85%; background: #F5F5F5;" |
+|LOAD
-* Israel (8.2%)
+|[[Levofloxacin]] 250mg PO
-* Saudi Arabia (4%)
+[[PPI]] double dose PO
+[[Nitazoxanide]] 500mg<sup>c</sup>
+[[Doxycycline]] 100mg PO
+|QD
+QD
+BID
+QD
+|7-10 days
+|NO
 |-
-! style="font-size: 85%; background: #DCDCDC;" | Far East
+|
+| colspan="4" |'''†''': Several PPI, Clarithromycin, and Amoxicillin combinations have achieved FDA approval, PPI, Clarithromycin, Metronidazole are not an FDA approved treatment regimen.
+'''‡:''' [[PPI]], [[Bismuth]], [[Tetracycline]], and [[metronidazole]] prescribed separately are not an FDA approved treatment regimen. However, Pylera, a combination product containing Bismuth subcitrate, Tetracycline, Metronidazole combination with PPI for 10 days is an FDA approved regimen.
+*BID, twice daily; FDA, Food and Drug Administration; PPI, proton pump inhibitor; TID, three times daily; QD, once daily; QID, four times daily.
+c: [[Metronidazole]] or [[Tinidazole]]<ref name="urlwww.nature.com">{{cite web |url=https://www.nature.com/ajg/journal/v112/n2/pdf/ajg2016563a.pdf |title=www.nature.com |format= |work= |accessdate=}}</ref>
+<small>*Adopted:American college of gasteroenterology<ref name="urlManagement of Patients with Ulcer Bleeding | American College of Gastroenterology">{{cite web |url=https://gi.org/guideline/management-of-patients-with-ulcer-bleeding/ |title=Management of Patients with Ulcer Bleeding &#124; American College of Gastroenterology |format= |work= |accessdate=}}</ref> </small>
+|}
+===Persistent Helicobacter Pylori infection ===
+With declining success rates for [[H. pylori]] eradication therapy, many patients will be persistently infected after treatment and will therefore remain at risk for the complications of [[H. pylori]]-related disease, such as [[peptic]] [[ulceration]] and [[gastric]] [[malignancy]], testing to prove eradication should be performed using a [[urea breath test]], fecal antigen test or biopsy-based testing at least 4 weeks after the completion of [[antibiotic]] therapy and after [[PPI]] therapy has been withheld for 1–2 weeks.In patients with persistent [[H. pylori]] infection, every effort should be made to avoid [[antibiotics]] that have been previously taken by the patient.<ref name="urlwww.nature.com">{{cite web |url=https://www.nature.com/ajg/journal/v112/n2/pdf/ajg2016563a.pdf |title=www.nature.com |format= |work= |accessdate=}}</ref><ref name="pmid17608775">{{cite journal |vauthors=Chey WD, Wong BC |title=American College of Gastroenterology guideline on the management of Helicobacter pylori infection |journal=Am. J. Gastroenterol. |volume=102 |issue=8 |pages=1808–25 |year=2007 |pmid=17608775 |doi=10.1111/j.1572-0241.2007.01393.x |url=}}</ref>
+{{familytree/start}}
+{{familytree| | | | | | | | | | | | | | | | | | A01 | | | | | |A01=Persistent [[Helicobacter Pylori]] infection }}
+{{familytree| | | | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| |}}
+{{familytree| | | | | | | | | B01 | | | | | | | | | | | | | | | | B02 ||B01=Patient recieved [[clarithromycin]] triple therapy|B02=Patient received [[Bismuth]] quadriple therapy }}
+{{familytree| | |,|-|-|-|v|-|-|^|-|-|v|-|-|-|.| | | |,|-|-|-|v|-|-|^|-|-|v|-|-|-|.|}}
+{{familytree|boxstyle=text-align: left; | C01 | | C02 | | | | C03 | | C04 | | C05 | | C06 | | | | C07 | | C08 | |C01= •No previous Quinolone exposure<br>•No PCN allergy<br>'''Recomended treatment:'''<br> •[[Bismuth]] quadruple<br> •[[Levofloxacin]]<br> •[[Rifabutin]] triple<br> •High dose dual|C02= •Previous Quinolone exposure<br> •No PCN Allergy<br>'''Recomended treatment:'''<br> •[[Bismuth]] quadruple therapy<br> •Rifabutin triple<br> •High dose dual<br>|C03= •No previous Quinolone exposure<br> •PCN Allergy<br> '''Recomended treatment:'''<br>•[[Bismuth]] quadruple| C04=•Previous Quinolone exposure<br> •PCN Allergy<br>'''Recomended treatment:'''<br> •[[Bismuth]] quadruple<br>|C05=•No previous Quinolone exposure<br>•No PCN allergy<br>'''Recomended treatment:'''<br>•[[Levofloxacin]] triple concomitant<br>•Rifabutin triple<br>•High dose triple<br>|C06=•Previous Quinolone exposure<br> •No PCN Allergy<br>'''Recomended treatment:'''<br>•Concomitant Rifabutin triple <br>•High dose dual<br>|C07=•No previous Quinolone<br> exposure<br> •PCN Allergy<br> '''Recomended treatment:'''<br>•[[PPI]],[[Clarithromycin]]<br>,[[Metronidazole]]<br>•[[PPI]],[[Levofloxacin]],<br>[[Metronidazole]]|C08=•Previous Quinolone exposure<br> •No PCN Allergy<br>'''Recomended treatment:'''<br> •[[PPI]],[[Clarithromycin]],<br>[[Metronidazole]]<br>•[[Bismuth]] quadruple }}
+{{familytree/end}} Adopted:American college of gasteroenterology[17]
+====Salvage treatment====
+After the failure of first-line therapy, such patients should be considered for referral for salvage treatment.
+{| class="wikitable"
+! colspan="5" |Salvage therapies for Helicobacter pylori infection
 |-
-| style="font-size: 85%; background: #F5F5F5;" |
+|Regimen
-* Bangladesh (10%)
+|Drugs(doses)
-* Hong Kong (4.5%)
+|Dosing frequency
-* Korea (14%)
+|Duration(days)
-* Malaysia (2.1%)
+|FDA approval
-* New Zealand (11%)
 |-
-! style="font-size: 85%; background: #545454; color: #F8F8FF; padding: 5px 10px;" | Countries with a reported prevalence ≥ 15% of ''H. pylori'' resistance to clarithromycin
+|[[Bismuth]] quadruple
+|
+* [[PPI]] standard dose PO
+* [[Bismuth]] subcitrate 120-300mg or sub salicylate 300mg
+* [[Tetracycline]] 500mg
+|BID
+QID
+QID
+TID or QID
+|14
+|NO<sup>(a)</sup>
+|-
+|[[Levofloxacin]] triple
+|
+* [[PPI]] standard dose
+* [[Levofloxacin]] 500mg
+* [[Amoxicillin]] 1gm
+|BID
+QD
+BID
+|14
+|NO
 |-
-! style="font-size: 85%; background: #DCDCDC;" | Europe
+|Concomitant
+|
+* [[PPI]] standard dose
+* [[Clarithromycin]] 500mg
+* [[Amoxicillin]] 1gm
+* [[Nitroimidazole]] 500mg
+|BID
+BID
+BID
+BID or TID
+|10-14
+|NO
 |-
-| style="font-size: 85%; background: #F5F5F5;" |
+|[[Rifabutin]] triple
-* Bulgaria (18.4%)
+|
-* France (20%)
+* [[PPI]] standard dose
-* Italy (central) (23.4%)
+* [[Rifabutin]] 300mg
-* Portugal (22%)
+* [[Amoxicillin]] 1gm
-* Spain (49.2%)
+|BID
-* Turkey (48.2%)
+QD
+BID
+|10
+|NO
 |-
-! style="font-size: 85%; background: #DCDCDC;" | South America
+|High-dose dual
+|
+* [[PPI]] standard to double dose
+* [[Amoxicillin]] 1gm TID or 750mg QID
+|TID or QID
+TID or QID
+|14
+|NO
+|}
+(a)[[PPI]],[[Bismuth]],[[Tetracycline|tetracyclin]] and [[metronidazole]] prescribed separately is not an FDA-approved treatment regimen.However,Pylera,a combination product containing [[bismuth]] subcitrate,[[tetracycline]] and [[metronidazole]] combined with a [[PPI]] for 10 days is an [[FDA-]]<nowiki/>approved treatment regimen
+*BID, twice daily; FDA, Food and Drug Administration; [[PPI]]-[[proton pump inhibitor]]; TID-three times daily; QD-once daily; QID-four times daily<ref name="urlwww.nature.com">{{cite web |url=https://www.nature.com/ajg/journal/v112/n2/pdf/ajg2016563a.pdf |title=www.nature.com |format= |work= |accessdate=}}</ref>
+Adopted:American college of gasteroenterology[17]
+====Medical therapy for Non Helicobacter pylori-associated Peptic ulcer disease:====
+* [[NSAIDs]] is most common cause of non-[[helicobacter pylori]] associated [[peptic ulcer]] disease
+* First step in management is to stop taking NSAIDs
+* Medical treatment for [[NSAIDs]] associated [[peptic ulcer]] :
+H2- receptor Antagonist
+* [[Cimetidine]] 800 mg
+* [[Ranitidine]]/[[Niizatidine]] 300 mg
+* [[Famotidine]] 40 mg
+[[Proton pump inhibitor|Proton pump inhibitors]]
+* [[Omeprazole]] 20 mg
+* [[Lansoprazole]] 30 mg
+* [[Rabeprazole]] 20 mg
+* [[Pantoprazole]] 40 mg
+{| class="wikitable"
+! colspan="2" |Prevention of NSAID-induced ulcers
 |-
-| style="font-size: 85%; background: #F5F5F5;" |
+|Drug
-* Mexico (25%)
+|Dose
 |-
-! style="font-size: 85%; background: #DCDCDC;" | Middle East
+|[[Misoprostol]]
+|200 μg q8h
 |-
-| style="font-size: 85%; background: #F5F5F5;" |
-* Iran (17%)
+|Drug
+|Dose
 |-
-! style="font-size: 85%; background: #DCDCDC;" | Far East
+|[[Misoprostol]]
+|200 μg  q8h
 |-
-| style="font-size: 85%; background: #F5F5F5;" |
+|Proton pump inhibitors
-* China (18%)
+* [[Omeprazole]] 20 mg
-* India (33%)
+* [[Lansoprazole]] 30 mg
-* Japan (27.7%)
+* [[Rabeprazole]] 20 mg
+* [[Pantoprazole]] 40 mg
+|q 24 hourly
+|}
+'''Treatment of ulcer according to stage of ulcer :'''
+{| class="wikitable"
+! colspan="2" |Active Ulcer
+|-
+!Drug
+!Dose
+|-
+|H2- receptor Antagonist
+* [[Cimetidine]] 800 mg
+* [[Ranitidine]]/nizatidine 300 mg
+* [[Famotidine]] 40 mg
+|q 24 hourly(night)
+|-
+|Proton pump inhibitors
+* [[Omeprazole]] 20 mg
+* [[Lansoprazole]] 30 mg
+* [[Rabeprazole]] 20 mg
+* [[Pantoprazole]] 40 mg
+|q 24 hourly(empty stomach)
+|-
+| colspan="2" |'''Maintenance therapy'''
+|-
+|H2-receptor antagonists
+* [[Cimetidine]] 400 mg
+* [[Ranitidine]]/nizatidine 150 mg
+* [[Famotidine]] 20 mg
+|q 24 hourly(at night)
+|-
+|Proton pump inhibitors
+* [[Omeprazole]] 20 mg
+* [[Lansoprazole]] 30 mg
+* [[Rabeprazole]] 20 mg
+* [[Pantoprazole]] 40 mg
+|q 24 hourly (empty stomach)
 |}
-===Diagnostic testing===
+==Contraindicated Medications==
-The American Journal of Gastroenterology guidelines recommend that '''endoscopy''' should be performed to rule out [[peptic ulcer disease]], esophagogastric [[malignancy]], and other rare upper gastrointestinal tract disease in the following settings:
+{{MedCondContrAbs|MedCond = Bleeding peptic ulcer|Ketorolac tromethamine|Mefenamic acid|Ticlopidine|Prasugrel|Reserpine|Streptokinase|Vorapaxar}}
-* [[Dyspeptic]] patients <u>more than 55 years old</u> {{or2}}
-* [[Dyspeptic]] patients with <u>alarm features</u>
-:* [[Bleeding]]
-:* [[Anemia]]
-:* [[Early satiety]]
-:* Unexplained [[weight loss]] (> 10% body weight)
-:* Progressive [[dysphagia]]
-:* [[Odynophagia]]
-:* Persistent [[vomiting]]
-:* A family history of gastrointestinal cancer
-:* Previous esophagogastric [[malignancy]]
-:* Previous documented [[peptic ulcer]], [[lymphadenopathy]], or an abdominal mass
-In patients aged 55 years or younger with no alarm features, two management options may be considered:
-* '''Test-and-treat strategy''' using a validated noninvasive test (urea breathing test or stool antigen test) for ''[[H. pylori]]'' and a trial of acid suppression if eradication is successful but symptoms do not resolve – preferable in populations with a moderate to high prevalence of ''[[H. pylori]]'' infection (≥ 10%)
-* '''Empiric trial of acid suppression''' with a [[proton pump inhibitor]] for 4–8 weeks – preferable in low prevalence situations
-Repeat [[endoscopy]] is not recommended once a firm diagnosis of functional [[dyspepsia]] has been established, unless new symptoms or alarm features develop.<ref>{{Cite journal| doi = 10.1111/j.1572-0241.2005.00225.x| issn = 0002-9270| volume = 100| issue = 10| pages = 2324–2337| last1 = Talley| first1 = Nicholas J.| last2 = Vakil| first2 = Nimish| last3 = Practice Parameters Committee of the American College of Gastroenterology| title = Guidelines for the management of dyspepsia| journal = The American Journal of Gastroenterology| date = 2005-10| pmid = 16181387}}</ref>  Testing to prove ''[[H. pylori]]'' eradication is most accurate if performed 4 weeks after the completion of therapy.<ref>{{Cite journal| doi = 10.1136/gutjnl-2012-302084| issn = 1468-3288| volume = 61| issue = 5| pages = 646–664| last1 = Malfertheiner| first1 = Peter| last2 = Megraud| first2 = Francis| last3 = O'Morain| first3 = Colm A.| last4 = Atherton| first4 = John| last5 = Axon| first5 = Anthony T. R.| last6 = Bazzoli| first6 = Franco| last7 = Gensini| first7 = Gian Franco| last8 = Gisbert| first8 = Javier P.| last9 = Graham| first9 = David Y.| last10 = Rokkas| first10 = Theodore| last11 = El-Omar| first11 = Emad M.| last12 = Kuipers| first12 = Ernst J.| last13 = European Helicobacter Study Group| title = Management of Helicobacter pylori infection--the Maastricht IV/ Florence Consensus Report| journal = Gut| date = 2012-05| pmid = 22491499}}</ref>
-===Treatment strategies===
-* The use of high-dose (twice a day) [[PPI|proton pump inhibitor (PPI)]] increases the efficacy of triple therapy.
-: [[Lansoprazole]] 30 mg q12h {{or2}}
-: [[Omeprazole]] 20 mg q12h {{or2}}
-: [[Esomeprazole]] 40 mg q24h {{or2}}
-: [[Rabeprazole]] 20 mg q12h
-* 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.<ref>{{Cite journal| doi = 10.1136/gutjnl-2012-302084| issn = 1468-3288| volume = 61| issue = 5| pages = 646–664| last1 = Malfertheiner| first1 = Peter| last2 = Megraud| first2 = Francis| last3 = O'Morain| first3 = Colm A.| last4 = Atherton| first4 = John| last5 = Axon| first5 = Anthony T. R.| last6 = Bazzoli| first6 = Franco| last7 = Gensini| first7 = Gian Franco| last8 = Gisbert| first8 = Javier P.| last9 = Graham| first9 = David Y.| last10 = Rokkas| first10 = Theodore| last11 = El-Omar| first11 = Emad M.| last12 = Kuipers| first12 = Ernst J.| last13 = European Helicobacter Study Group| title = Management of Helicobacter pylori infection--the Maastricht IV/ Florence Consensus Report| journal = Gut| date = 2012-05| pmid = 22491499}}</ref>
-==Eradication Therapy for ''Helicobacter pylori'' Infection==
-===First-line therapies===
-{{rx|Triple therapy (PCA or PCM regimen)}}
-* '''[[Proton pump inhibitor]]''' (standard dose twice daily) for 7–14 days {{and}}
-* '''[[Clarithromycin]]''' (500 mg twice daily) for 7–14 days {{and}}
-* '''[[Amoxicillin]]''' (1 g twice daily) for 7–14 days {{or}} '''[[Metronidazole]]''' (250 mg four times daily) for 7–14 days
-</li>
-{{rx|Quadruple therapy}}
-* '''[[Proton pump inhibitor]]''' (standard dose twice daily) for 10–14 days {{and}}
-* '''[[Metronidazole]]''' (250 mg four times daily) for 10–14 days {{and}}
-* '''[[Tetracycline]]''' (500 mg four times daily) for 10–14 days {{and}}
-* '''[[Bismuth]]''' (dose depends on preparation) for 10–14 days
-</li>
-{{rx|Sequential therapy}}
-* '''[[Proton pump inhibitor]]''' (standard dose twice daily) for 5 days {{and}}
-* '''[[Amoxicillin]]''' (1 g twice times daily) for 5 days<BR><span style="text-indent: 50px;">'''<u>FOLLOWED BY</u>'''</span>
-* '''[[Proton pump inhibitor]]''' (standard dose twice daily) for another 5 days {{and}}
-* '''[[Clarithromycin]]''' (500 mg twice daily) for another 5 days {{and}}
-* '''[[Tinidazole]]''' (500 mg twice daily) for another 5 days
-</li>
-===Second-line therapies===
-{{rx|Triple therapy (PLA regimen)}}
-* '''[[Proton pump inhibitor]]''' (standard dose twice daily) for 10 days {{and}}
-* '''[[Levofloxacin]]''' (500 mg twice daily) for 10 days {{and}}
-* '''[[Amoxicillin]]''' (1 g twice daily) for 10 days
-</li>
-{{rx|Triple therapy (PMA regimen)}}
-* '''[[Proton pump inhibitor]]''' (standard dose twice daily) for 7–14 days {{and}}
-* '''[[Metronidazole]]''' (250 mg four times daily) for 7–14 days {{and}}
-* '''[[Amoxicillin]]''' (1 g twice daily) for 7–14 days
-</li>
-{{rx|Triple therapy (PRA regimen)}}
-* '''[[Proton pump inhibitor]]''' (standard dose twice daily) for 10 days {{and}}
-* '''[[Rifabutin]]''' (150–300 mg/day) for 10 days {{and}}
-* '''[[Amoxicillin]]''' (1 g twice daily) for 10 days
-</li>
-==Algorithm for the Approach to Dyspepsia==
-<div style="font-size: 80%;">
-{{Familytree/start}}
-{{Familytree|boxstyle=border: 0;| | | | | | A01 | | | | | | | | | | |A01={{F1|Age ≥ 55 or ⊕ alarm features?}}}}
-{{Familytree|boxstyle=border: 0;| |,|-|-|-|-|^|-|-|-|-|.| | | | | | |}}
-{{Familytree|boxstyle=border: 0;| B01 | | | | | | | | B02 | | | | | |B01={{F1|YES}}|B02={{F1|NO}}}}
-{{Familytree|boxstyle=border: 0;| |!| | | | | | | | | |!| | | | | | |}}
-{{Familytree|boxstyle=border: 0;| C01 | | | | | | | | C02 | | | | | |C01={{F2|Endoscopy}}|C02={{F1|''H. pylori'' prevalence?}}}}
-{{Familytree|boxstyle=border: 0;| |!| | | | |,|-|-|-|-|^|-|-|-|-|.| |}}
-{{Familytree|boxstyle=border: 0;| |!| | | | D01 | | | | | | | | D02 |D01={{F1|High}}|D02={{F1|Low}}}}
-{{Familytree|boxstyle=border: 0;| |!| | | | |!| | | | | | | | | |!| |}}
-{{Familytree|boxstyle=border: 0;| |!| | | | E01 | | | | | | | | E02 |E01={{F2|Test-and-treat strategy}}|E02={{F2|Acid suppression trial}}}}
-{{Familytree|boxstyle=border: 0;| |`|-|-|-|-|+|-|-|-|-|-|-|-|-|-|'| |}}
-{{Familytree|boxstyle=border: 0;| | | | | | F01 | | | | | | | | | | |F01={{F1|If treatment is indicated}}}}
-{{Familytree|boxstyle=border: 0;| |,|-|-|-|-|^|-|-|-|-|.| | | | | | |}}
-{{Familytree|boxstyle=border: 0;| G01 | | | | | | | | G02 | | | | | |G01={{F1|Clarithromycin resistance ≥ 15%}}|G02={{F1|Clarithromycin resistance < 15%}}}}
-{{Familytree|boxstyle=border: 0;| |!| | | | | | | | | |!| | | | | | |}}
-{{Familytree|boxstyle=border: 0;| H01 | | | | | | | | H02 | | | | | |H01={{F2|Quadruple or sequential therapy}}|H02={{F2|PCA or PCM regimen}}}}
-{{Familytree|boxstyle=border: 0;| |!| | | | | | | | | |!| | | | | | |}}
-{{Familytree|boxstyle=border: 0;| I01 | | | | | | | | I02 | | | | | |I01={{F2|PLA regimen}}|I02={{F2|Quadruple therapy or PLA regimen}}}}
-{{Familytree|boxstyle=border: 0;| |`|-|-|-|-|v|-|-|-|-|'| | | | | | |}}
-{{Familytree|boxstyle=border: 0;| | | | | | F01 | | | | | | | | | | |F01={{F1|Adjust Rx per susceptibility test}}}}
-{{Familytree/end}}
-</div>
-[[file:Dyspepsia3.png|thumb|right|300px|Algorithm for the management of uninvestigated dyspepsia.]]
-==Contraindicated Medications==
-{{MedCondContrAbs|MedCond = Bleeding peptic ulcer|Ketorolac tromethamine|Mefenamic acid|Ticlopidine|Prasugrel|Reserpine|Streptokinase|Vorapaxar}}
 ==Guidelines and Resources==
@@ Line 190: / Line 385: @@
 ==References==
 {{reflist|2}}
+<references />
 [[Category:Abdominal pain]]
 [[Category:Disease]]
 [[Category:Gastroenterology]]
-[[Category:Primary care]]

Peptic ulcer medical therapy: Difference between revisions

Latest revision as of 23:37, 29 July 2020

Overview

Medical Therapy

Eradication Therapy for Helicobacter pylori Infection

Indications

Triple Therapy

Bismuth-containing quadruple therapy

Non–Bismuth-containing quadruple therapy

Persistent Helicobacter Pylori infection

Salvage treatment

Medical therapy for Non Helicobacter pylori-associated Peptic ulcer disease:

Contraindicated Medications

Guidelines and Resources

References

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