{"id":675,"date":"2015-04-15T02:00:44","date_gmt":"2015-04-15T02:00:44","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=675"},"modified":"2017-08-21T11:51:08","modified_gmt":"2017-08-21T11:51:08","slug":"primary-care-corner-with-geoffrey-modest-md-h-pylori-rescue-therapy","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/04\/15\/primary-care-corner-with-geoffrey-modest-md-h-pylori-rescue-therapy\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: H. pylori rescue therapy"},"content":{"rendered":"

By: Dr. Geoffrey Modest\u00a0<\/strong><\/p>\n

Most of the cure rates for H. pylori infections are in the 80-90% range, leaving many people with persistent infections. \u00a0There have been several articles on rescue therapy, including a recent one with a relatively easy regimen and 90% efficacy\u00a0(see Aliment Pharmacol Ther 2015; 41: 768\u2013775). \u00a0This Spanish\/Italian study looked at 200 patients who failed several different initial therapies. details:<\/p>\n

–17 hospitals involved in study (15 Spanish, 2 Italian)<\/p>\n

–200 patients (mean age 47, 67% women, 13% had ulcers),\u00a0having had\u00a0the following prior therapies: 131\u00a0patients had \u00a0standard PPI-clarithromycin-amoxacillin, 32 with sequential (PPI-amoxacillin x 5 days, then PPI-clarithromycin-metronidazole x 5 days), 37 with quad therapy of\u00a0PPI-amoxacillin-clarithromycin-metronidazole for 10 days. Failure was defined as a positive\u00a013<\/sup>C-urea breath test 4-8 weeks after therapy.
\n–all were put on esomeprazole 40mg bid, amoxicillin 1gm bid, levofloxacin 500 mg in the evening, and bismuth subcitrate 240mg bid for 14 days
\n–primary outcome: eradication rate confirmed by breath test, as above<\/p>\n

–results: 180\/200 patients (90%), in intention-to-treat analysis, and 175\/192 (91%), on per-protocol anaylsis, had cures. Similar results in Spain and Italy, whether diagnosis was peptic ulcer or dyspepsia, or with the type of prior treatment (eg: success in 88.5% on standard triple therapy, 93.8% on sequential therapy, and 91.9% on quad therapy)
\n–adverse events in 46% (mostly nausea in 17%, diarrhea in 16%, abdominal pain in 15%, metallic taste in 15%), but these were time-limited to the 14 days of treatment and only 6 (3%) felt the adverse effects were “intense”, though none were considered serious.<\/p>\n

So, why did this therapy work so well?<\/p>\n

–The role of bismuth is likely a major part: bismuth is not itself associated with bacterial resistance,\u00a0is synergistic with\u00a0antibiotics, overcomes clarithromycin and levofloxacin\u00a0resistance, and\u00a0has efficacy in setting of metronidazole resistance. Purported additional\u00a0mechanisms of action: decreases mucin viscosity, binds to toxins produced by h pylori, is adherent to gastric epithelium and prevents bacterial colonization, and reduces the bacterial load.<\/p>\n

–Although H pylori resistance to fluoroquinolones is increasing (up to 24% in Europe and 13% in Spain), other studies have found that the addition of bismuth dramatically increased eradication rates to a regimen of PPI,\u00a0amoxacillin, and levofloxacin for 14 days, finding no difference when the h pylori was sensitive to levofloxacin (85%), but when levofloxacin-resistance was present, adding bismuth increased eradication from 37% to 71%.<\/p>\n

–The longer 14-day regimen, which has been found in several studies to improve eradication rates<\/p>\n

–The use of high dose esomeprazole. ??the role of the high dosage of 40mg (some studies have found 6-10% higher cure rates with higher doses of PPI). \u00a0??the role of the newer PPI (some data that esomeprazole and rabeprazole are better than the first-generation PPIs)<\/p>\n

So, this was a large study of patients with documented primary treatment failure and very high response rates to a 14-day course of quadruple-therapy containing bismuth. Although there were no data presented\u00a0on resistance patterns of the h pylori, it seems very likely that there were many resistant bacteria (given prevailing resistance patterns). Unfortunately, \u200bin the US we have very little data (none I can find in Boston),\u00a0where h pylori is basically an imported infection from many different parts of the world with differing resistance patterns. Clinically, i have had good success with the sequential therapy noted above. But this bismuth therapy seems\u00a0to be a good one for treatment failure. Although it makes sense to use the regimen they prescribe above in order to get their results, I would opt for high dose pantoprazole or omeprazole, given the difficulty in getting esomeprazole through insurance.<\/p>\n","protected":false},"excerpt":{"rendered":"

H. pylori rescue therapy […]<\/p>\n

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