Peptic ulcer medical therapy: Difference between revisions

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! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Triple therapy}}
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Triple therapy}}
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Lansoprazole]] 30 mg q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Lansoprazole]] 30 mg q12h'''''<br> OR <br> ▸ '''''[[Omeprazole]] 20 mg q12h'''''<br> OR <br> ▸ '''''[[Esomeprazole]] 40 mg q24h'''''<br> OR <br> ▸ '''''[[Rabeprazole]] 20 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Omeprazole]] 20 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Esomeprazole]] 40 mg q24h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Rabeprazole]] 20 mg q12h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
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! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Triple therapy}}
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center| {{fontcolor|#FFF|Triple therapy}}
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Lansoprazole]] 30 mg q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Lansoprazole]] 30 mg q12h'''''<br> OR <br> ▸ '''''[[Omeprazole]] 20 mg q12h'''''<br> OR <br> ▸ '''''[[Esomeprazole]] 40 mg q24h'''''<br> OR <br> ▸ '''''[[Rabeprazole]] 20 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Omeprazole]] 20 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Esomeprazole]] 40 mg q24h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Rabeprazole]] 20 mg q12h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
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| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''First 5 days'''''
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''First 5 days'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Lansoprazole]] 30 mg q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Lansoprazole]] 30 mg q12h'''''<br> OR <br> ▸ '''''[[Omeprazole]] 20 mg q12h'''''<br> OR <br> ▸ '''''[[Esomeprazole]] 40 mg q24h'''''<br> OR <br> ▸ '''''[[Rabeprazole]] 20 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Omeprazole]] 20 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Esomeprazole]] 40 mg q24h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Rabeprazole]] 20 mg q12h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
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| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Next 5 days'''''
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Next 5 days'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Lansoprazole]] 30 mg q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Lansoprazole]] 30 mg q12h'''''<br> OR <br> ▸ '''''[[Omeprazole]] 20 mg q12h'''''<br> OR <br> ▸ '''''[[Esomeprazole]] 40 mg q24h'''''<br> OR <br> ▸ '''''[[Rabeprazole]] 20 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Omeprazole]] 20 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Esomeprazole]] 40 mg q24h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Rabeprazole]] 20 mg q12h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
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| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''First 7 days'''''
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''First 7 days'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Lansoprazole]] 30 mg q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Lansoprazole]] 30 mg q12h'''''<br> OR <br> ▸ '''''[[Omeprazole]] 20 mg q12h'''''<br> OR <br> ▸ '''''[[Esomeprazole]] 40 mg q24h'''''<br> OR <br> ▸ '''''[[Rabeprazole]] 20 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Omeprazole]] 20 mg q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Esomeprazole]] 40 mg q24h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | OR
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Rabeprazole]] 20 mg q12h'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS

Revision as of 15:38, 16 June 2014

Peptic ulcer Microchapters

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Case #1

2017 ACG Guidelines for Peptic Ulcer Disease

Guidelines for the Indications to Test for, and to Treat, H. pylori Infection

Guidelines for First line Treatment Strategies of Peptic Ulcer Disease for Providers in North America

Guidlines for factors that predict the successful eradication when treating H. pylori infection

Guidelines to document H. pylori antimicrobial resistance in the North America

Guidelines for evaluation and testing of H. pylori antibiotic resistance

Guidelines for when to test for treatment success after H. pylori eradication therapy

Guidelines for penicillin allergy in patients with H. pylori infection

Guidelines for the salvage therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Guillermo Rodriguez Nava, M.D. [2]

Overview

  • Treatment of H. pylori usually leads to clearing of infection, relief of symptoms and eventual healing of ulcers. Recurrence of infection can occur and retreatment may be required, if necessary with other antibiotics. Since the widespread use of PPI's in the 1990s, surgical procedures (like "highly selective vagotomy") for uncomplicated peptic ulcers became obsolete.

Principles of Eradication Therapy for Helicobacter pylori infection

  1. Indications for diagnosis and treatment, established:[1]
    1. Active peptic ulcer disease.
    2. Confirmed history of peptic ulcer disease not previously treated for H. pylori.
    3. Gastric MALT lymphoma.
    4. After endoscopic resection of early gastric cancer.
    5. Uninvestigated dyspepsia (review H. pylori prevalence).
  2. Low clarithromycin resistance areas (<15%):[2]
    1. In areas of low resistance the PPI-clarithromycin-containing triple therapy is recommended as the first-line treatment as well as bismuth-containing quadruple therapy.
    2. In areas of low resistance after failure of a PPI-clarithromycin-containing treatment, either a bismuth-containing quadruple therapy or levofloxacin-containing triple therapy is recommended.
  3. High clarithromycin resistance areas (≥15%):[2]
    1. In areas of high resistance, bismuth-containing quadruple therapy are recommended for first-line treatment.
    2. In areas of high resistance after failure of bismuth containing quadruple therapy, levofloxacin containing triple therapy is recommended.
  4. After failure of second-line treatment, treatment should be guided by antimicrobial susceptibility testing.[2]
  5. FDA approved first line regimens duration:[1]
    1. Triple therapy: 7 days (10 days if rabeprazole).
    2. Quadruple therapy: 4 weeks.
  6. Confirm the eradication of H. pylori infection in patients who have had an H. pylori-associated ulcer or gastric MALT lymphoma or who have undergone resection for early gastric cancer.[3]
  7. The urea breathing test is the most reliable nonendoscopic test to document eradication of H. pylori infection.[1]
  8. Testing to prove H. pylori eradication is most accurate if performed at 4 weeks after the completion of eradication therapy.[3]


Countries with a reported prevalence <15% of H. pylori resistance to clarithromycin[4][5][6][7]
Europe North America South America Middle East Far East
  • Belgium (3%)
  • Croatia (8.2%)
  • Denmark (11%)
  • Finland (2%)
  • Germany (2.2–4%)
  • Italy (North) (1.8%)
  • Ireland (8.8%)
  • Netherlands (1.7%)
  • Sweden (2.9%)
  • UK (8.3–12.7%)
  • Canada (12%)
  • USA (10.6–12.2%)
  • Brazil (9.8%)
  • Israel (8.2%)
  • Saudi Arabia (4%)
  • Bangladesh (10%)
  • Hong Kong (4.5%)
  • Korea (14%)
  • Malaysia (2.1%
  • New Zealand (11%)

There is a reported prevalence of 15% in the Northeast of the US.

Countries with a reported prevalence ≥15% of H. pylori resistance to clarithromycin[4][5][6][7]
Europe North America Middle East Far East
  • Bulgaria (18.4%)
  • France (20%)
  • Italy (central) (23.4%)
  • Portugal (22%)
  • Spain (49.2%)
  • Turkey (48.2%)
  • Mexico (25%)
  • Iran (17%)
  • China (18%)
  • India (33%)
  • Japan (27.7%)
  • Taiwan (13.5)

Helicobacter pylori Eradication Therapies

▸ Click on the following categories to expand treatment regimens.[1][8][9][3][10][11]

First line

  ▸  Triple therapy

  ▸  Quadruple therapy

Second line

  ▸  Triple therapy

  ▸  Sequential therapy

  ▸  Hybrid therapy

Third line therapy (Rescue therapy)

  ▸  Rifabutin based

Triple therapy
Lansoprazole 30 mg q12h
OR
Omeprazole 20 mg q12h
OR
Esomeprazole 40 mg q24h
OR
Rabeprazole 20 mg q12h
PLUS
Clarithromycin 500 mg q12h.
PLUS
Amoxicillin 1 g q12h
Quadruple therapy
Bismuth subsalicylate 525 mg orally q6h
PLUS
Metronidazole 250 mg orally q6h
PLUS
Tetracycline 500 mg orally q6h
PLUS
Ranitidine 150 mg orally q12h
OR
PPI standard dose
Triple therapy
Lansoprazole 30 mg q12h
OR
Omeprazole 20 mg q12h
OR
Esomeprazole 40 mg q24h
OR
Rabeprazole 20 mg q12h
PLUS
Clarithromycin 500 mg q12h
PLUS
Metronidazole 500 mg q12h
Sequential therapy
First 5 days
Lansoprazole 30 mg q12h
OR
Omeprazole 20 mg q12h
OR
Esomeprazole 40 mg q24h
OR
Rabeprazole 20 mg q12h
PLUS
Amoxicillin 1 g q12h
Next 5 days
Lansoprazole 30 mg q12h
OR
Omeprazole 20 mg q12h
OR
Esomeprazole 40 mg q24h
OR
Rabeprazole 20 mg q12h
PLUS
Clarithromycin 500 mg q12h
PLUS
Tinidazole 500 mg q12h
Sequential therapy
First 7 days
Lansoprazole 30 mg q12h
OR
Omeprazole 20 mg q12h
OR
Esomeprazole 40 mg q24h
OR
Rabeprazole 20 mg q12h
PLUS
Amoxicillin 1 g q12h
Next 7 days
PPI standard dose
PLUS
Amoxicillin 1 g q12h
PLUS
Clarithromycin 500 mg q12h
PLUS
Metronidazole 500 mg q12h
Third line treatment
Rifabutin 150 mg q2h
PLUS
Amoxicillin 1 g IV q12h
PLUS
Ciprofloxacin 500 mg/kg IV q12h

References

  1. 1.0 1.1 1.2 1.3 Chey WD, Wong BC, Practice Parameters Committee of the American College of Gastroenterology (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.
  2. 2.0 2.1 2.2 Malfertheiner P, Megraud F, O'Morain CA, Atherton J, Axon AT, Bazzoli F; et al. (2012). "Management of Helicobacter pylori infection--the Maastricht IV/ Florence Consensus Report". Gut. 61 (5): 646–64. doi:10.1136/gutjnl-2012-302084. PMID 22491499.
  3. 3.0 3.1 3.2 McColl KE (2010). "Clinical practice. Helicobacter pylori infection". N Engl J Med. 362 (17): 1597–604. doi:10.1056/NEJMcp1001110. PMID 20427808.
  4. 4.0 4.1 Mégraud F (2004). "H pylori antibiotic resistance: prevalence, importance, and advances in testing". Gut. 53 (9): 1374–84. doi:10.1136/gut.2003.022111. PMC 1774187. PMID 15306603.
  5. 5.0 5.1 Duck WM, Sobel J, Pruckler JM, Song Q, Swerdlow D, Friedman C; et al. (2004). "Antimicrobial resistance incidence and risk factors among Helicobacter pylori-infected persons, United States". Emerg Infect Dis. 10 (6): 1088–94. doi:10.3201/eid1006.030744. PMC 3323181. PMID 15207062.
  6. 6.0 6.1 De Francesco V, Giorgio F, Hassan C, Manes G, Vannella L, Panella C; et al. (2010). "Worldwide H. pylori antibiotic resistance: a systematic review". J Gastrointestin Liver Dis. 19 (4): 409–14. PMID 21188333.
  7. 7.0 7.1 Boyanova L, Mitov I (2010). "Geographic map and evolution of primary Helicobacter pylori resistance to antibacterial agents". Expert Rev Anti Infect Ther. 8 (1): 59–70. doi:10.1586/eri.09.113. PMID 20014902.
  8. Garza-González E, Perez-Perez GI, Maldonado-Garza HJ, Bosques-Padilla FJ (2014). "A review of Helicobacter pylori diagnosis, treatment, and methods to detect eradication". World J Gastroenterol. 20 (6): 1438–49. doi:10.3748/wjg.v20.i6.1438. PMC 3925853. PMID 24587620.
  9. O'Connor A, Molina-Infante J, Gisbert JP, O'Morain C (2013). "Treatment of Helicobacter pylori infection 2013". Helicobacter. 18 Suppl 1: 58–65. doi:10.1111/hel.12075. PMID 24011247.
  10. Song M, Ang TL (2014). "Second and third line treatment options for Helicobacter pylori eradication". World J Gastroenterol. 20 (6): 1517–28. doi:10.3748/wjg.v20.i6.1517. PMC 3925860. PMID 24587627.
  11. Majumdar, Debabrata; Bebb, James; Atherton, John (2007). "Helicobacter pylori infection and peptic ulcers". Medicine. 35 (4): 204–209. doi:10.1016/j.mpmed.2007.01.006. ISSN 1357-3039.


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