Peptic ulcer medical therapy
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Peptic ulcer Microchapters |
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Diagnosis |
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Treatment |
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Surgery |
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Case Studies |
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2017 ACG Guidelines for Peptic Ulcer Disease |
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Guidelines for the Indications to Test for, and to Treat, H. pylori Infection |
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Guidlines for factors that predict the successful eradication when treating H. pylori infection |
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Guidelines to document H. pylori antimicrobial resistance in the North America |
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Guidelines for evaluation and testing of H. pylori antibiotic resistance |
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Guidelines for when to test for treatment success after H. pylori eradication therapy |
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Guidelines for penicillin allergy in patients with H. pylori infection |
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Peptic ulcer medical therapy On the Web |
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American Roentgen Ray Society Images of Peptic ulcer medical therapy |
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Risk calculators and risk factors for Peptic ulcer medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Gerald Chi, M.D.
Overview
Eradication of Helicobacter pylori with antimicrobial agents is indicated for patients with gastric or duodenal peptic ulceration, who are colonized with H. 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. Pharmacologic therapies for peptic ulcer disease due to H. pylori involve triple or quadruple drug therapy that includes Proton pump inhibitors with a combination of antimicrobial agents. The use of antimicrobial therapy is discouraged in asymptomatic carriers.
Medical Therapy
| Countries with a reported prevalence < 15% of H. pylori resistance to clarithromycin |
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| Europe |
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| North America |
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| South America |
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| Middle East |
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| Far East |
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| Countries with a reported prevalence ≥ 15% of H. pylori resistance to clarithromycin |
| Europe |
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| South America |
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| Middle East |
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| Far East |
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Diagnostic testing
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:
- 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.[1] Testing to prove H. pylori eradication is most accurate if performed 4 weeks after the completion of therapy.[2]
Treatment strategies
- The use of high-dose (twice a day) proton pump inhibitor (PPI) increases the efficacy of triple therapy.
- Lansoprazole 30 mg q12h
OR - Omeprazole 20 mg q12h
OR - Esomeprazole 40 mg q24h
OR - 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.[3]
Eradication Therapy for Helicobacter pylori Infection
Triple Therapy
- PCA 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
- PCM regimen
- Proton pump inhibitor (standard dose twice daily) for 7–14 days AND
- Clarithromycin (500 mg twice daily) for 7–14 days AND
- Metronidazole (250 mg four times daily) for 7–14 days
- 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
- 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
- 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
Quadruple Therapy
Bismuth-Containing Quadruple Therapy
- Bismuth 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
Non–Bismuth-Containing Quadruple Therapy
- Concomitant therapy
- 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 10 days AND
- Metronidazole (250 mg four times daily) for 7–14 days
- Sequential therapy
- Proton pump inhibitor (standard dose twice daily) for 5 days AND
- Amoxicillin (1 g twice times daily) for 5 days
FOLLOWED BY - 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
Algorithm for the Approach to Dyspepsia
| Age ≥ 55 or ⊕ alarm features? | |||||||||||||||||||||||||||||||||||||
| YES | NO | ||||||||||||||||||||||||||||||||||||
| Endoscopy | H. pylori prevalence? | ||||||||||||||||||||||||||||||||||||
| High | Low | ||||||||||||||||||||||||||||||||||||
| Test-and-treat strategy ± acid suppression | Acid suppression trial | ||||||||||||||||||||||||||||||||||||
| If eradication therapy is indicated | |||||||||||||||||||||||||||||||||||||
| Clarithromycin resistance ≥ 20% | Clarithromycin resistance < 20% | ||||||||||||||||||||||||||||||||||||
| Quadruple or sequential therapy | PCA or PCM or Bismuth quadruple therapy | ||||||||||||||||||||||||||||||||||||
| PLA | Bismuth quadruple therapy or PLA | ||||||||||||||||||||||||||||||||||||
| Adjust Rx per susceptibility test | |||||||||||||||||||||||||||||||||||||
| Consider endoscopy if treatment fails | |||||||||||||||||||||||||||||||||||||
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.[4]
- American Society for Gastrointestinal Endoscopy (ASGE) – The role of endoscopy in dyspepsia.[5]
- American Society for Gastrointestinal Endoscopy (ASGE) – The role of endoscopy in gastroduodenal obstruction and gastroparesis.[6]
- 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.[7]
- The European Helicobacter Study Group (EHSG) – Management of Helicobacter pylori infection.[8]
References
- ↑ 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) - ↑ 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) - ↑ 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) - ↑ 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)