2015-07-15 15:08:39 UTC

Treatment of H. Pylori: Is Eradication Really the Best Strategy?

July 11, 2015

Dr. Graham provides his perspective on the problems of H. pylori eradication at the patient and physician level.

David Y. Graham, MD

David Y. Graham, MD

Department of Medicine, Michael E. DeBakey VA Medical Center, and Baylor College of Medicine Houston, TX

This article appears in the June/July 2015 issue of AGA Perspectives.

H. pylori is an infectious disease that I believe humans would be better off without. We have entered a new era. In 2013, the Japanese government approved population-wide H. pylori eradication. In 2014, WHO published a monograph on H. pylori eradication as a strategy of elimination of gastric cancer. Finally, in 2015, the Global Consensus on H. pylori gastritis published in Gut and recommended overall H. pylori eradication. Suggestions that H. pylori might provide a benefit have not withstood critical examination and are no longer an issue.

Worldwide, hundreds of millions of individuals are H. pylori-infected and most reside in regions already burdened with poverty and other major public health problems. While the goal to eradicate H. pylori is clear, the path to achieving that goal will need to be both population- and region-specific. I agree with the edict that all diagnosed H. pylori infections should be eradicated unless there are compelling reasons not to do so. We can all think of a few reasons (i.e., too old, too sick, etc).

Here, I discuss the problems of H. pylori eradication at the level of the patient and their physician. H. pylori is an infectious disease. It would be simple to cure (greater than 95 percent success) if one could reliably choose antimicrobials to which the infection is susceptible. Unlike other common infectious diseases, culture of H. pylori is generally unavailable and physicians must attempt to predict susceptibility using experience or by playing the odds. Clarithromycin susceptibility testing can be easily and reliably assessed using molecular methods on gastric biopsies or even from stools, but even that is rarely available. Experience relies on knowing what is successful in one's population. This knowledge, combined with the patient's medical history and pharmacy records, allows one to narrow the choices regarding which antibiotics to use.

Macrolides and fluoroquinolones suffer from cross resistance; prior use of a drug of these types (e.g., azithromycin or ciprofloxacin) generally means the infection is resistant and should eliminate them from empiric use (i.e., cure rates with any triple therapy such as PPI, amoxicillin and clarithromycin, metronidazole, or a fluoroquinolone is 10 percent or less with resistance infections). Amoxicillin, tetracycline and metronidazole, when part of 14-day bismuth quadruple therapy, can be reused. It is important not have false expectations based on published results (noting 85 percent success rates) as the overall result reflect the results of averaging a high success group with susceptible strains and very poor success with resistant strains. No patient achieves the reported 85 percent, but instead would fall into one of those two groups (i.e., under 10 or over 90 percent).

If necessary to treat empirically, I suggest one know two equivalent first-line alternatives. I use concomitant therapy (PPI omeprazole 40 mg or equivalent, 500 mg clarithromycin, 500 mg metronidazole, and 1000 mg amoxicillin, b.i.d. for 14 days) or bismuth quadruple therapy (PPI, omeprazole 40 mg or equivalent b.i.d., 500 mg metronidazole t.i.d., 500 mg tetracycline q.i.d. and bismuth such as Pepto Bismol2 tablets q.i.d. for 14 days).

While the goal to eradicate H. pylori is clear, the path to achieving that goal will need to be both population- and region-specific.

Concomitant therapy is undermined only by dual clarithromycinmetronidazole resistance and is generally well tolerated. Tetracycline may be difficult to obtain; it is available from Canada. Our experience is that doxycycline is not an adequate substitute. The commercial product, Pylera, is packaged for 10-day therapy and the PPI must be prescribed separately. In the U.S., Pylera is expensive, often $400 for 10 days. We prescribe 14-day therapy and it often costs $600 or more. Generic therapy costs about $40 at Walmart.

Adherence to the prescribed regimen is a problem with all H. pylori therapies and it is worth the time and effort to discuss the importance of finishing the prescription and the expected side effects with the patient. Bismuth quadruple therapy is especially useful in the presence of penicillin allergy or to treat patients who have failed another regimen. Sequential therapy and triple therapy (i.e., PrevPac or an equivalent) are still widely used but are obsolete for empiric use. Concomitant and sequential therapy contain the same drugs but concomitant will always be equal or superior to sequential therapy. I believe that all patients should have a test of cure (i.e., urea breath test or stool antigen test) as only cured patients benefit from therapy. In addition, this information provides data regarding individual therapies in your patient population (i.e, what works, and what no longer works). For suggestions regarding the difficult patient (i.e., prior treatment failure, drug allergies, etc.) or details regarding above, see my recent reviews in Gastroenterology and Clinical Gastroenterology and Hepatology.

Dr. Graham is a consultant for RedHill Biopharma regarding novel H. pylori therapies and has received research support for culture of H. pylori. He is a consultant for Otsuka Pharmaceuticals regarding diagnostic breath testing and for BioGaia in relation to probiotic therapy for H. pylori infection.

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