TOC   |  GI   

Dyspepsia                              REF:  h_pylori 2010.pdf

Acid-Peptic Disease  

Uncomplicated Dyspepsia (with or without history of ulcer):

• In the absence of GERD or alarm symptoms (e.g., vomiting, weight loss, dysphagia, jaundice, G.I. bleeding, or anemia), serology testing for H.pylori is recommended.

Treatment of H.pylori                   See also Helicobacter Foundation Site  

The Standard regimen:  3-drug regimen given for ONE WEEK is recommended as first-line therapy for eradication of H.pylori in patients who test positive:

1. Pantoprazole (Protonix) 40 mg BID (#14 x 40mg), plus
2. Clarithromycin (Biaxin) 500 mg BID (#14 x 500mg), plus
3. Amoxicillin 1 gram BID (#28 x 500mg)  or may use Metronidazole/Flagyl 500 mg BID if amoxicillin is not tolerated.  

Sequential regimen:   (REF:  Ann Intern Med Jan 17, 2006;144:94-100 De Francesco V, etc.)
(REF: Meta-analysis: Sequential Therapy Appears Superior to Standard Therapy for Helicobacter pylori Infection in Patients Naive to Treatment.   Nadim S. Jafri, MD, MSc; Carlton A. Hornung, PhD, MPH; and Colin W. Howden, MD 17 June 2008 | Volume 148 Issue 12)

The Sequential regimen was more effective than standard regimen in eradicating both susceptible & resistant H.pylori strains.

1. Proton-pump inhibitor (as Rabeprazole) + Amoxicillin 1 gam BID  x 5 days, then
2. Proton-pump inhibitor (as Rabeprazole) + Clarithromycin /Biaxin + Tinidazole (or metronidazole/Flagyl)  for the next 5 days

Antimicrobial agents with activity against H. pylori include metronidazole, tetracycline, amoxicillin, clarithromycin, and fluoroquinolones such as levofloxacin.
Most popular in the United States are 10- to 14-day combination regimens, although 7-day courses may be almost as effective and are more popular in Europe.
A 2-week course of a three-drug regimen that includes a proton pump inhibitor, clarithromycin, and amoxicillin has a success rate approaching 90%.
One recent study from Italy demonstrated close to 90% efficacy with a 7-day levofloxacin-based triple therapy; the efficacy rate exceeded those of standard (amoxicillin-based or metronidazole-based) 7-day triple therapies by 10% to 15%, suggesting that this regimen can be an alternative to standard 10-day and 14-day regimens for first-line therapy.  
[Nista EC, Candelli M, Zocco MA, et al: Levofloxacin-based triple therapy in first-line treatment for Helicobacter pylori eradication. Am J Gastroenterol 101:1985, 2006]

JCOM Feb 2002  "Abbreviated Regimens for H. pylori Eradication in PUD"  

Treatment of Dyspeptic Symptoms

§ Lifestyle Modification

• - Withdrawal of ulcerogenic substances (e.g., ASA, NSAIDs, alcohol, tobacco)
• - Avoid foods that precipitate symptoms (e.g., chocolate, caffeine, spicy foods)

§ If symptoms persist after lifestyle modification and/or H. Pylori treatment, treat with:

• - High-dose H2 antagonists: Famotidine (Pepcid) 40 mg BID or Ranitidine (Zantac) 300 mg BID and/or
• - OTC antacids as needed

* Treatment with high-dose H2 antagonists should not continue for longer than 8 weeks.

If symptoms persist after 8 weeks, then reevaluation of the patient's medical history is necessary.

Back-to-top  |  Home Page   

2010