To discuss the epidemiology, pathogenesis, and diagnosis of H. pylori

To discuss the epidemiology, pathogenesis, and diagnosis of H. pylori

• To discuss the epidemiology, pathogenesis, and diagnosis of H. pylori

• To highlight test and treat practice guidelines

• To compare and contrast clinical trial results between quadruple and triple therapy

• To review antibiotic treatments

MB is 29 Cambodian and has been in the US for 5 years.

• MB is 29 Cambodian and has been in the US for 5 years.

• She lives in the inner city of Los Angeles.

• History: 1 - month of moderate mid-epigastric, upper abdominal pain.

• No complaints of gas, darkening stool, or heartburn.

• Non-smoker, no other medical problems, occasional ibuprofen usage.

Describe the epidemiology of H. pylori.

• Describe the epidemiology of H. pylori.

• Review the pathogenesis of H. pylori and associated symptoms.

Estimated 50-60% of the world population is infected

• Estimated 50-60% of the world population is infected

• Person to Person Transmission

• fecal-oral, oral-oral, gastro-oral

• Increased risk of infection

• younger age
• underdeveloped countries
• lower socioeconomic status

1890’s: Spirochetes in animal stomachs

• 1890’s: Spirochetes in animal stomachs

• 1900’s: Spirochetes in human stomachs

• 1954: No bacteria in gastric biopsies of 1000 patients

• 1975: Gram negative bacteria in 80% of GU’s (Pseudomonas)

• 1983: Warren and Marshall characterize H. pylori

• 2005 Nobel prize in 2005

Demographics – Cambodian, inner city

• Demographics – Cambodian, inner city

• Pathogenesis: immune and inflammatory response contribute to symptoms

SH is 34 y/o middle income social worker in Austin, TX.

• SH is 34 y/o middle income social worker in Austin, TX.

• Receiving proton pump inhibitor (PPI).

• 6 - month history of dyspepsia with no improvement in symptoms.

• Smoker and no family history of GI cancer.

• Never had endoscopy.

Describe active and passive tests for detection of H. pylori .

• Describe active and passive tests for detection of H. pylori .

• Discuss various diagnostic tests for H. pylori .

• Review practice guidelines and application for test and treat.

Results

• Results

• 1/3 antibiotics for H. pylori had no test
• 1/3 post-treatment PCPs used serologic test
• 2/3 ages 50 - 64 years underwent endoscopy
• 1/3 ages 18 - 49 years had an endoscopy within 30 days of their index date
• 18% GERD patients tested for H. pylori

• “Substantial noncompliance with guidelines”

• “Better understanding of test and treat”

High prevalence area – Austin.

• High prevalence area – Austin.

• Test and treat guidelines apply.

• PPI therapy false negative on UBT and SAT.

• Hold PPI 2 weeks prior to UBT and SAT.

• Wait 1 month post eradication therapy to recheck.

“ The modern treatment of peptic ulcers places emphasis on diet and rest.

• “ The modern treatment of peptic ulcers places emphasis on diet and rest.

• The patient is fed a bland diet, and small meals are given at frequent intervals.

• Milk, cream and protein hydrolysates are often prescribed between meals.

• Rest is essential. Some gastroenterologist routinely recommend hospitalization for several weeks…..

• Mild sedatives are frequently beneficial.”

Bismuth subcitrate potassium, metronidazole tetracycline (BMT)

• Bismuth subcitrate potassium, metronidazole tetracycline (BMT)

• not bismuth subsalicylate
• 3-in-1 capsule

• Four studies with BMT 2-3 capsules QID for 7-10 days ± PPI1-4

• Up to 93% compliance, >75% medication taken3

In vitro resistance varies with test method

• In vitro resistance varies with test method

• 39% (690/1768) E-test
• 25.7% (317/1234) agar dilution

• Strategies to combat resistance

• longer duration, PPI-BMT, high dose MTZ

Objectives

• Objectives

• to assess the efficacy and safety BMT + omeprazole in the eradication of H. pylori
• to investigate effect of MTZ resistance and disease type (peptic ulcer vs. non-ulcer dyspepsia) on the eradication rates

Methods

• Methods

• open label, international multicenter
• dyspepsia +/- PUD, testing positive for H. pylori by 13C-UBT
• histology and ⁄ or culture of 5 pre-treatment biopsies
• 3 BMT QID + OME 20mg BID X 10 days
• 29 & 57 days post therapy 2 negative 13C-UBT after treatment

DU = duodenal ulcer

• DU = duodenal ulcer

DU healing with histamine-2 receptor antagonist (H2RA) vs. H2RA based quadruple therapy

• DU healing with histamine-2 receptor antagonist (H2RA) vs. H2RA based quadruple therapy

• Bismuth subsalicylate

• Patients were assessed for H. pylori infection via:

• 13C UBT
• serology (IgG)
• culture
• histologic evaluation

• Low eradication rates (81%)

Pylera contains the following in each capsule:

• Pylera contains the following in each capsule:

• metronidazole 125 mg
• tetracycline 125 mg
• bismuth subcitrate potassium 140 mg

• 3-in-1 capsule available with these ingredients in the US

Known hypersensitivity or intolerance to:

• Known hypersensitivity or intolerance to:

• bismuth subcitrate potassium
• metronidazole or other nitroimidazoles
• tetracyclines
• components of the formulation

• Renal or hepatic impairment

• Pregnant and nursing women

• Pediatric patients

Bismuth: darkening of tongue and/or black stool

• Bismuth: darkening of tongue and/or black stool

• Metronidazole: history of blood dyscrasias

• Tetracycline: candidiasis

• Avoid tanning booths, use sunscreen

• Avoid alcohol

• Missed doses continuing dosing schedule until the medication is gone and do not take double doses

• If more than 4 doses are missed, the prescriber should be contacted

Tetracycline:

• Tetracycline:

• prolonged INR in patients on warfarin
• reduced absorption with antacids, including calcium, magnesium, aluminum.
• reduced absorption with iron, zinc, multivitamins
• concurrent use of may render oral contraceptives less effective and patients should be advised to use a different or additional form of contraception

Metronidazole:

• Metronidazole:

• may increase lithium levels
• Disulfiram reaction with alcohol
• prolonged INR in patients on warfarin
• metabolism may be increased by phenytoin or phenobarbital

Most common adverse events

• Most common adverse events

• Stool abnormality (15.6%)
• Diarrhea (8.8%)
• Dyspepsia (8.8%)
• Abdominal Pain (8.8%)
• Nausea (8.2%)
• Headache (8.2%)
• Taste perversion (4.8%)
• Vaginitis (4.1%)

H. pylori is the major cause of DU and it should be eradicated in all patients testing positive

• H. pylori is the major cause of DU and it should be eradicated in all patients testing positive

• H. pylori relationship with the development of MALT and gastric cancer

• As high as 93% (158/170) eradication rate of H. pylori when quadruple therapy is used1

• Eradication rates vary between triple and quadruple therapies