GI Exam 2 Part 5: Helicobacter pylori-induced Peptic Ulcer Disease

what are possible symptoms of H. pylori PUD

o Heartburn, abdominal pain

o Loss of appetite, weight loss

o Iron deficiency anemia (bacteria sequester dietary iron & body unable to absorb)

o Ulcers, upper GI bleeding

how are asymptomatic H. pylori PUD patients treated?

usually not treated, only if FH of HGI cancer

over-treating asymptomatic patients can result in resistance

how is H. pylori PUD diagnosed

·      Stool antigen test

·      Blood titers

·      Upper GI endoscopy

·      Culture from gastric biopsy

·      Urea breath test

how does the urea breath test work?

·      Swallow drink containing urea enriched with carbon isotope

·      H pylori is a urease producer, hydrolyzes urea to ammonia and CO2

·      If patient has a CO2 positive breath test then they are positive for H. Pylori

PPIs and urea breath test

PPIs must be discontinued 2 weeks prior (can cause a false negative)

4 treatment goals of H. pylori PUD

· Eradicate H Pylori infection

· Relieve pain associated with peptic ulcer disease and promote peptic ulcer healing

· Prevent peptic ulcer recurrence and complications (bleeding, obstruction, perforation)

· Adult patients who receive treatment should have other adult family members in the same household tested due to oral/ fecal transmission

which treatment of H. pylori PUD is no longer recommended and why?

Clarithromycin triple therapy due to increased resistance rates

**New England reisstance rates do meet criteria though

what are the 2 first-line treatments for H. pylori PUD

bismuth quadruple therapy (BQT)

PCAB clarithromycin triple therapy

clarithromycin triple therapy

BID PPI + BID clarithromycin + BID amoxicillin for 14 days

PrevPac

o   Lansoprazole + amoxicillin + clarithromycin all BID x 14 day supply

o   Daily patient cards split into AM and PM

o considered clarithromycin triple therapy so not recommended

bismuth quadruple therapy

·      PPI BID + bismuth subsalicylate QID + metronidazole TID-QID + tetracycline QID x 14 days

safe for patients with a penicillin allergy

pylera

o   Bismuth + metronidazole + tetracycline

§  Need 3 capsules QID

§  Does not include PPI, separate RX is required

how long is pylera dosed for?

only available as a 10 day supply even though 14 days is optimal

reduced time course causes a reduced eradication rate

tetracycline vs doxycycline in bismuth quadruple therapy

doxycycline can increase treatment failure

-may be substituted for tetracycline due to cost and availability

why is pylera not contraindicated in those with aspirin allergies?

because the bismuth is subcitrate not subsalicylate

helidac

o   Bismuth + metronidazole + tetracycline

o   Dispensed as a 14 day regimen

o   Approved by the FDA to be given in conjunction with H2 antagonists (but should be given with PPI)

not recommended by the guidelines

dosing frequency of bismuth quadruple therapy

QID

what are the 3 medications in PCAB clarithromycin triple therapy

- vonoprazan

- clarithromycin

- amoxicillin

2 clinical pearls of PCAB clarithromycin therapy

- avoid if any macrolide (azithromycin) use

- all drugs BID

PCAB clarithromycin triple therapy

· BID dosing x 14 days

Vonoprazan, clarithromycin, and amoxicillin

only should be used if clarithromycin rates are known

which patients should NOT recieve PCAB Clarithromycin therapy

patients with a penicillin allergy

recent use of macrolide antibiotics (azithromycin)

why is the BID PPI so important?

·      H. pylori replicates best at neutral pH

·      Acid inhibition with PPI raises pH at site of infection to allow for more growth

o   Antibiotics used are growth-dependent antibiotics, meaning they better target the bacteria when it is replicating

o   Increases efficacy of growth-dependent antibiotics

o   Antibiotics are more stable and have higher activity at higher pHs

o   Continuous periods with intragastric pH>6 significantly associated with successful treatment  rationale for PCAB use

clarithromycin DDIs

strong CYP3A4 inhibitor

2 side effects of clarithromycin

diarrhea, QTc prolongation

amoxicillin shold be avoided in which patients

those with a true penicillin allergy

metronidazole ADEs

o N

o Metallic taste

o Furry tongue

o Darkened urine

what should be avoided with mitronidazole

alcohol (disulfuram reaction)

tetracycline DDI

separate from antacids

ADEs of tetracycline

N, esophageal irritation

what are side effects of all antibiotics

NVD

what are 4 causes of H/ pylori treatment failure

o Non-adherence (frequency, duration of therapy)

o Low intragastric pH

o High bacterial inoculum

o Antibiotic resistance, incorrect treatment regimen

when to follow up with H. pylori treatment

confirmation of eradication should be tested at 4 weeks