Who to treat?
This has always been a controversial question in the management of H.pylori infection.
The current Maastricht-3 consensus strongly recommends the following groups be treated.
Peptic ulcer disease – active or not including complicated ulcer
Mucosa-associated lymphoid tissue lymphoma (MALToma)
Post-gastric cancer resection
Patients who are first-degree relatives of gastric cancer patients
Patients’ wishes – after full consultation with their physician
In other cases Hp eradication may be advisable after careful assessment of the case
GERD if long term acid suppression required or antral predominant gastritis
Prior to NSAID use
Iron deficiency anaemia
As is apparent above the issue regarding treatment is generally less clear when H. pylori is found outside the setting of peptic ulcer disease. Given a 10 percent lifetime risk of developing peptic ulcer disease and an increased incidence of gastric adenocarcinoma it is probably advisable to eradicate. The mild increase in reflux associated with eliminating corpus gastritis does not seem to outweigh these risks and the risk of impact on probability of esophageal adenocarcinoma is insignificant. There is no compelling reason to permit persistent H. pylori infection once it has been demonstrated. The only good H. pylori is a dead H. pylori!
How to treat?
A “test and treat and retest” policy must always pertain with regard to H.pylori eradication treatment. It should not be prescribed empirically. Following the completion of therapy, eradication must be confirmed as the failure rates with most regimes are in the region of 20% due to the intertwined problems of drug resistance and poor compliance.
First line therapy
Proton pump inhibitor + clarithromycin 500mg + amoxicillin 1g (all twice daily) for 10 to 14 days.
Where clarithromycin resistance exceeds 20%, use metronidazole 400mg bd instead of clarithromycin. If penicillin allergy documented, use metronidazole instead of amoxicillin.
If first line therapy is unsuccessful, some options exist regarding second line. Some authorities advocate quadruple therapy with PPI, amoxicillin, metronidazole and clarithromycin. This however is of questionable efficacy and promotes resistance. Bismuth is helpful for second line but difficult to source in Ireland. A useful option is proton pump inhibitor + levofloxacin 500mg + amoxicillin 1g (all twice daily) for 10 to 14 days. However in this case we must bear in mind safety concerns regarding quinolones and tendonitis and liver dysfunction.
Third line/Rescue therapy
At this stage, endoscopy and biopsy should be considered to enable sensitivity testing. Rifabutin represents a useful option. It must however be used sparingly as this drug is useful in the treatment of multidrug resistant Tuberculosis and may cause myelotoxicity.
PPI + Rifabutin 150mg + Amoxycillin 1g (all twice daily) for 10 to 14 days
This is a new adaptation of first line therapy where amoxicillin is taken twice daily for the first five days of therapy and subsequently stopped. clarithromycin and metronidazole are then taken for the next five days. PPI therapy continues throughout the ten days. This aims to overcome resistance by weakening the bacterial wall in the first phase of therapy but is largely unproven outside of Italy and may make compliance with therapy more difficult.