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Current Status of Treatment for H. pylori Infection



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Am Fam Physician. 2000 Aug 1;62(3):630-633.

Helicobacter pylori infection is a potentially serious, chronic, transmissible disease with a long asymptomatic period. Up to 70 percent of infected persons have minimal symptoms, even in the absence of treatment. H. pylori infection is characterized primarily by progressive damage to gastric structure and function. H. pylori resides in the surface of the stomach within the mucous and is attached to mucous and epithelial cells. Symptomatic manifestations include peptic ulcer, a complication that eventually develops in approximately one in six infected persons. Infected persons also have an increased lifetime risk of gastric adenocarcinoma. H. pylori-related disease predominantly affects the elderly and minority populations; in the United States, immigrants are particularly affected. Unfortunately, the ultimate outcome of H. pylori infection is impossible to predict. Graham reviews the current strategies used for treating H. pylori infection.

The current “test and treat” strategy is rapidly being replaced with a three-step approach to management: diagnose, treat and confirm cure. The increasing availability of accurate and noninvasive tests, such as the urea breath and stool antigen tests, may make confirmation of cure practical. These tests may soon become the standard of care. Currently, the major obstacles to effective therapy are the presence of antibiotic-resistant H. pylori and poor compliance with the prescribed regimen.

Overall cure rates in clinical practice have been reported as high as 85 percent. The currently preferred therapies are outlined in the accompanying table. Studies of efficacy suggest that a higher dosage and a longer duration of treatment are more likely to be successful. For example, 14 days of treatment tend to be superior to 10 days, which tend to be superior to seven days. Acquired resistance to clarithromycin and metronidazole is a significant problem. Resistance to amoxicillin and tetracycline is rare. Increasing the amount of metronidazole from 1 to 1.5 g per day generally improves results in the treatment of metronidazole-resistant strains.

Preferred Therapies for Helicobacter pylori Infection

Twice-daily proton pump inhibitor or ranitidine bismuth citrate triple therapies*

A proton pump inhibitor or ranitidine bismuth citrate

plus

Two of the following: amoxicillin (1 g), clarithromycin (500 mg) or metronidazole (500 mg)

Quadruple therapy

A proton pump inhibitor twice daily

Tetracycline (500 mg) four times daily

Bismuth subsalicylate or subcitrate four times daily

Metronidazole (500 mg) three times daily


note: The rank order suggests that 14 days are superior to 10 days and that 10 days are superior to seven days.

*—The data suggest that there is no difference between ranitidine bismuth citrate and proton pump inhibitor triple therapies when the H. pylori are sensitive. There may be a slight advantage for ranitidine bismuth citrate triple therapies when resistant H. pylori are present.

Adapted with permission from Graham DY. Therapy of Helicobacter pylori: current status and issues. Gastroenterology 2000;118:S3.

Preferred Therapies for Helicobacter pylori Infection

View Table

Preferred Therapies for Helicobacter pylori Infection

Twice-daily proton pump inhibitor or ranitidine bismuth citrate triple therapies*

A proton pump inhibitor or ranitidine bismuth citrate

plus

Two of the following: amoxicillin (1 g), clarithromycin (500 mg) or metronidazole (500 mg)

Quadruple therapy

A proton pump inhibitor twice daily

Tetracycline (500 mg) four times daily

Bismuth subsalicylate or subcitrate four times daily

Metronidazole (500 mg) three times daily


note: The rank order suggests that 14 days are superior to 10 days and that 10 days are superior to seven days.

*—The data suggest that there is no difference between ranitidine bismuth citrate and proton pump inhibitor triple therapies when the H. pylori are sensitive. There may be a slight advantage for ranitidine bismuth citrate triple therapies when resistant H. pylori are present.

Adapted with permission from Graham DY. Therapy of Helicobacter pylori: current status and issues. Gastroenterology 2000;118:S3.

The author concludes that while the ideal therapy has not been identified, factors that may influence outcomes are beginning to become clear. Future studies should help clarify the most effective regimens and methods to confirm cure.

Graham DY. Therapy of Helicobacter pylori: current status and issues. Gastroenterology. February 2000;118:S2–8.



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