Gastritis medical therapy: Difference between revisions

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==Overview==
==Overview==
Medical therapy for gastritis depends on the cause, but commonly includes reducing stomach acidity (e.g., with proton pump inhibitors) or eradicating H. pylori infection with antibiotics.
Medical therapy for Gastritis depends on its specific cause. Medications known to cause gastritis such as NSAIDs (aspirin, naproxen, ibuprofen) should be discontinued. Smoking cessation and abstinence from alcohol consumption is recommended. Medications to decrease [[gastric acid]] production such as [[proton pump inhibitor]]s ([[PPI]]) are recommended. In cases of Helicobacter pylori infection, [[antimicrobial]] drugs are recommended. ''[[Helicobacter]]'' infection typically responds well to the ''triple therapy'' protocol (consisting of two [[antibiotic]]s, and a [[proton pump inhibitor]]). Regimens that work well include PCA or PCM triple therapy ([[PPI]], [[Clarithromycin]], [[Amoxicillin]]) or (PPI, clarithromycin, [[Metronidazole]]). Quadruple therapy has a >90% success rate and includes PPIs, bismuth subsalicylates, [[metronidazole]], and [[tetracycline]]. Indications for treatment of ''[[H. pylori]]'' infection include past or present [[duodenal ulcer|duodenal]] and/or [[gastric ulcer]], with or without complications, following resection of [[gastric cancer]], [[MALT lymphoma|gastric mucosa-associated lymphoid tissue (MALT) lymphoma]], atrophic gastritis, [[dyspepsia]], patients with first-degree relatives with gastric cancer and patient‘s wishes. Factors involved in choosing treatment regimens include [[prevalence]] of ''[[H. pylori]]'' infection, [[prevalence]] of [[gastric cancer]], resistance to [[antibiotics]], availability of [[bismuth]], availability of [[endoscopy]] and ''[[H. pylori]]'' tests, ethnicity, drug allergies and tolerance, previous treatments and outcome, adverse effects, effectiveness of local treatment and recommended dosages and treatment duration.


==Medical Therapy==
==Medical Therapy==
Medical therapy for gastritis depends on its specific cause.
*Medications known to cause gastritis such as NSAIDs (aspirin, naproxen, ibuprofen) should be discontinued.
*Abstinence from alcohol consumption is recommended
*Medications to neutralize stomach acid or decrease its production usually help in eliminating the symptoms and promote healing.
*Gastritis caused by pernicious anemia is treated with [[vitamin B12]].
*Gastritis due to [[stress]] is best treated by prevention. Medications to decrease [[gastric acid]] production such as [[proton pump inhibitor]]s ([[PPI]]) are recommended for stressed hospital patients.
*In cases of Helicobacter pylori infection, [[antimicrobial]] drugs are recommended.  ''[[Helicobacter]]'' infection typically responds well to the ''triple therapy'' protocol (consisting of two [[antibiotic]]s, and a [[proton pump inhibitor]]). Regimens that work well include PCA or PCM triple therapy ([[PPI]], [[clarithromycin]], [[amoxicillin]]) or (PPI, [[clarithromycin]], [[metronidazole]]). Quadruple therapy has a >90% success rate and includes PPIs, [[bismuth subsalicylate]], [[metronidazole]], and [[tetracycline]]. Indications for treatment of ''[[H. pylori]]'' infection include'':<ref name="pmid21961099">{{cite journal| author=Hunt RH, Xiao SD, Megraud F, Leon-Barua R, Bazzoli F, van der Merwe S et al.| title=Helicobacter pylori in developing countries. World Gastroenterology Organisation Global Guideline. | journal=J Gastrointestin Liver Dis | year= 2011 | volume= 20 | issue= 3 | pages= 299-304 | pmid=21961099 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21961099  }} </ref>''
**Past or present duodenal and/or gastric ulcer, with or without complications
**Following resection of [[gastric cancer]]
**[[MALT lymphoma|Gastric mucosa-associated lymphoid tissue (MALT) lymphoma]]
**[[Atrophic gastritis]]
**[[Dyspepsia]]
**Patients with first-degree relatives with [[gastric cancer]]
**Patients wishes


Treatment depends on the specific cause. Some of the causes will disappear over time.
Factors involved in choosing treatment regimens include:<ref name="pmid21961099">{{cite journal| author=Hunt RH, Xiao SD, Megraud F, Leon-Barua R, Bazzoli F, van der Merwe S et al.| title=Helicobacter pylori in developing countries. World Gastroenterology Organisation Global Guideline. | journal=J Gastrointestin Liver Dis | year= 2011 | volume= 20 | issue= 3 | pages= 299-304 | pmid=21961099 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21961099  }} </ref>
*Medications known to cause gastritis should be discontinued.
*Prevalence of ''[[H. pylori]] infection''
*Prevalence of [[gastric cancer]]
*Resistance to [[antibiotics]]
*Availability of [[bismuth]]
*Cost of tests
*Availability of [[endoscopy]] and ''[[H. pylori]]'' tests
*Ethnicity
*Drug allergies and tolerance
*Previous treatments and outcome
*Ease of administration
*Adverse effects
*Effectiveness of local treatment
*Recommended dosages and treatment duration


*Medications to neutralize stomach acid or decrease its production will usually eliminate the symptoms and promote healing.
===First-Line Regimens for Helicobacter pylori Eradication===
*[[Bismuth]] quadruple therapy has been advocated as a primary therapy for ''[[H. pylori]]''.
*In patients who have not previously received [[clarithromycin]] and who are not allergic to [[penicillin]], [[proton pump inhibitor|PPI]], [[clarithromycin]], and [[amoxicillin]] are considered.
*For patients allergic to [[penicillin]], [[metronidazole]] is given as an alternative for [[amoxicillin]].
*In patients who are allergic to [[penicillin]] or those who have previously been treated with a [[macrolide]] antibiotic, [[bismuth]] quadraple therapy is considered.
{| class="wikitable"
! style="text-align: center; width: 200px; style=" background:#4479BA; color: #FFFFFF; " + | Regimen
! style="text-align: center; width: 50px; style=" background:#4479BA; color: #FFFFFF; " + | Duration
! style="text-align: center; width: 50px; style=" background:#4479BA; color: #FFFFFF; " + | Eradication rates
! style="text-align: center; width: 100px; style=" background:#4479BA; color: #FFFFFF; " + | Comments
|-
|Standard dose [[proton pump inhibitor|PPI]] b.i.d. ([[esomeprazole]] is q.d.),
[[clarithromycin]] 500 mg b.i.d., [[amoxicillin]] 1,000 mg b.i.d.
|10–14
|70–85%
|Consider in nonpenicillin allergic patients who have not previously received a [[macrolide]]
|-
|Standard dose [[proton pump inhibitor|PPI]] b.i.d., [[clarithromycin]] 500 mg b.i.d.
[[metronidazole]] 500 mg b.i.d.
|10–14
|70–85%
|Consider in [[penicillin]] allergic patients who have not previously received a [[macrolide]] or are unable to tolerate [[bismuth]] quadruple therapy
|-
|[[Bismuth subsalicylate]] 525 mg p.o. q.i.d. [[metronidazole]]
250 mg p.o. q.i.d., [[tetracycline]] 500 mg p.o. q.i.d.,


*'''Vitamin B12:'''  Gastritis caused by pernicious anemia is treated with [[vitamin B12]].
[[ranitidine]] 150 mg p.o. b.i.d. or standard dose


*'''Proton pump inhibitors:'''  Gastritis due to [[stress]] is best treated by prevention. Medications to decrease [[gastric acid]] production such as [[proton pump inhibitor]]s ([[PPI]]) should be given to stressed hospital patients.
PPI q.d. to b.i.d.
|10–14
|75–90%
|Consider in [[penicillin]] allergic patients
|-
|[[proton pump inhibitor|PPI]] + [[amoxicillin]] 1 g b.i.d. followed by
[[proton pump inhibitor|PPI]], [[clarithromycin]] 500 mg, [[tinidazole]] 500 mg b.i.d.
|5


*'''Antibiotics''': In cases of infection, a doctor will most often prescribe [[antimicrobial]] drugs.  ''[[Helicobacter]]'' infection typically responds well to the ''triple therapy'' protocol (consisting of two [[antibiotic]]s, and a [[proton pump inhibitor]]). Regimens that work well include PCA or PCM triple therapy ([[PPI]], [[Clarithromycin]], [[Amoxicillin]]) or (PPI, Clarithromycin, [[Metronidazole]]). Quadruple therapy has a >90% success rate and includes PPIs, Bismuth subsalicylates, [[Metronidazole]], and [[Tetracycline]].
5
|>90%
|Requires validation in North America
|-
| colspan="4" |
|-
| colspan="4" style="background:#DCDCDC; + " | PPI = [[proton pump inhibitor]]; pcn = [[penicillin]]; p.o. = orally; q.d. = daily; b.i.d. = twice daily; t.i.d. = three times daily; q.i.d. = four times daily.
<nowiki>*</nowiki>Standard dosages for PPIs are as follows:


[[lansoprazole]] 30 mg p.o., [[omeprazole]] 20 mg p.o., [[pantoprazole]] 40 mg p.o., [[rabeprazole]] 20 mg p.o., [[esomeprazole]] 40 mg p.o.
Note: the above-recommended treatments are not all FDA approved.
|}
<br />
'''FDA approved regimens are as follows:'''
'''1.''' [[Bismuth]] 525 mg q.i.d. + [[metronidazole]] 250 mg q.i.d. + [[tetracycline]] 500 mg q.i.d. × 2 wk + H2RA as directed × 4 wk.
'''2.''' [[Lansoprazole]] 30 mg b.i.d. + [[clarithromycin]] 500 mg b.i.d. + [[amoxicillin]] 1 g b.i.d. × 10 days.
'''3.''' [[Omeprazole]] 20 mg b.i.d. + [[clarithromycin]] 500 mg b.i.d. + [[amoxicillin]] 1 g b.i.d. × 10 days.
'''4.''' [[esomeprazole]] 40 mg q.d. + [[clarithromycin]] 500 mg b.i.d. + [[amoxicillin]] 1 g b.i.d. × 10 days.
'''5.''' [[Rabeprazole]] 20 mg b.i.d. + [[clarithromycin]] 500 mg b.i.d. + [[amoxicillin]] 1 g b.i.d. × 7 days.
===Predictors of H.pylori Treatment Outcome===
Predictors of treatment failure include:
*Poor compliance
*Antibiotic resistance (key factor in the failure of eradication therapy and recurrence of ''[[H. pylori]]'' infection)
*Bacterial factors like CagA-negative strains are at increased risk of treatment failure compared with CagA-positive strains
*CYP2C 19 polymorphisms may influence treatment outcomes when regimens containing PPIs are used as they influence the clearance of PPIs and thus their effect on gastric acid secretion.
{| class="wikitable"
! style="background:#4479BA; color: #FFFFFF;" + | Drugs
! style="background:#4479BA; color: #FFFFFF;" + | Side effects
! style="background:#4479BA; color: #FFFFFF;" + | Recommendations
|-
| style="background:#DCDCDC; + " | [[Proton pump inhibitors|Proton pump inhibitors (PPIs)]]
|
* Headache
* [[Diarrhea]]
|[[Proton pump inhibitors|PPIs]] should be taken 30-60 min before eating to optimize their effects on gastric acid secretion.
|-
| style="background:#DCDCDC; + " | [[Clarithromycin]]
|
* GI upset
* Headache
* Altered taste
|
|-
| style="background:#DCDCDC; + " | [[Amoxicillin]]
|
* GI upset
* Headache
* [[Diarrhea]]
|
|-
| style="background:#DCDCDC; + " | [[Metronidazole]]
|
* Metallic taste in the mouth
* Dyspepsia
* A disulfiram-like reaction with alcohol consumption
|
|-
| style="background:#DCDCDC; + " | [[Tetracycline]]
|
* GI upset
* [[Photosensitivity]]
|[[Tetracyclinhes]] should not be given to children under 8 yr of age because of possible tooth discoloration
|-
| style="background:#DCDCDC; + " | [[Bismuth|Bismuth Compounds]]
|
* Darkening of tongue and stool
* [[Nausea]]
* GI upset
|
|}
===Salvage Therapy for Persistent H.pylori Infection===
*In patients with persistent [[H. pylori]] infection, every effort should be made to avoid [[antibiotics]] that have been previously taken by the patient''.<ref name="pmid12144577">{{cite journal| author=Isakov V, Domareva I, Koudryavtseva L, Maev I, Ganskaya Z| title=Furazolidone-based triple 'rescue therapy' vs. quadruple 'rescue therapy' for the eradication of Helicobacter pylori resistant to metronidazole. | journal=Aliment Pharmacol Ther | year= 2002 | volume= 16 | issue= 7 | pages= 1277-82 | pmid=12144577 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12144577  }} </ref>''
*Bismuth-based quadruple therapy for 7-14 days is an accepted salvage therapy.
*[[Levofloxacin]]-based triple therapy for 10 days is another option in patients with persistent infection, which requires validation in the United States.
{| class="wikitable"
! style="background:#4479BA; color: #FFFFFF;" + | Regimen
! style="background:#4479BA; color: #FFFFFF;" + | Duration
! style="background:#4479BA; color: #FFFFFF;" + | Eradication rates
! style="background:#4479BA; color: #FFFFFF;" + | Comments
|-
| style="background:#DCDCDC; + " | Bismuth quadruple therapy
PPI q.d. [[tetracycline]], [[Pepto Bismol]], [[metronidazole]] q.i.d.
|7
|68%
|Accessible, cheap but high pill count, and frequent mild side effects
|-
| style="background:#DCDCDC; + " | [[Levofloxacin]] triple therapy
[[proton pump inhibitor|PPI]], [[amoxicillin]] 1 g b.i.d., [[levofloxacin]] 500 mg q.d.
|10
|10 87%
|Requires validation in North America
|}
*Triple therapy should be used if a patient has persistent [[infection]] who has previously not been treated with [[clarithromycin]].
*In patients who were treated with [[clarithromycin]] initially, bismuth quadruple therapy is used as salvage therapy.
'''Other Alternative Antibiotics'''
'''Rifabutin'''
*[[Rifabutin]] is used as an alternate [[antibiotic]] in patients with [[clarithromycin]] or [[metronidazole]] resistance.<ref name="pmid16842467">{{cite journal| author=Miehlke S, Hansky K, Schneider-Brachert W, Kirsch C, Morgner A, Madisch A et al.| title=Randomized trial of rifabutin-based triple therapy and high-dose dual therapy for rescue treatment of Helicobacter pylori resistant to both metronidazole and clarithromycin. | journal=Aliment Pharmacol Ther | year= 2006 | volume= 24 | issue= 2 | pages= 395-403 | pmid=16842467 | doi=10.1111/j.1365-2036.2006.02993.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16842467  }} </ref><ref name="pmid11197288">{{cite journal| author=Perri F, Festa V, Clemente R, Villani MR, Quitadamo M, Caruso N et al.| title=Randomized study of two "rescue" therapies for Helicobacter pylori-infected patients after failure of standard triple therapies. | journal=Am J Gastroenterol | year= 2001 | volume= 96 | issue= 1 | pages= 58-62 | pmid=11197288 | doi=10.1111/j.1572-0241.2001.03452.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11197288  }} </ref><ref name="pmid11034001">{{cite journal| author=Bock H, Koop H, Lehn N, Heep M| title=Rifabutin-based triple therapy after failure of Helicobacter pylori eradication treatment: preliminary experience. | journal=J Clin Gastroenterol | year= 2000 | volume= 31 | issue= 3 | pages= 222-5 | pmid=11034001 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11034001  }} </ref><ref name="pmid12622764">{{cite journal| author=Wong WM, Gu Q, Lam SK, Fung FM, Lai KC, Hu WH et al.| title=Randomized controlled study of rabeprazole, levofloxacin and rifabutin triple therapy vs. quadruple therapy as second-line treatment for Helicobacter pylori infection. | journal=Aliment Pharmacol Ther | year= 2003 | volume= 17 | issue= 4 | pages= 553-60 | pmid=12622764 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12622764  }} </ref><ref name="pmid16441468">{{cite journal| author=Borody TJ, Pang G, Wettstein AR, Clancy R, Herdman K, Surace R et al.| title=Efficacy and safety of rifabutin-containing 'rescue therapy' for resistant Helicobacter pylori infection. | journal=Aliment Pharmacol Ther | year= 2006 | volume= 23 | issue= 4 | pages= 481-8 | pmid=16441468 | doi=10.1111/j.1365-2036.2006.02793.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16441468  }} </ref>
*Side effects include rash, [[nausea]], [[vomiting]], [[dyspepsia]], [[diarrhea]], [[myelotoxicity]] and [[ocular toxicity]]
'''Furazolindone'''
*[[Furazolidone]] is used as an alternative to [[clarithromycin]], [[metronidazole]], or [[amoxicillin]]<ref name="pmid12144577">{{cite journal| author=Isakov V, Domareva I, Koudryavtseva L, Maev I, Ganskaya Z| title=Furazolidone-based triple 'rescue therapy' vs. quadruple 'rescue therapy' for the eradication of Helicobacter pylori resistant to metronidazole. | journal=Aliment Pharmacol Ther | year= 2002 | volume= 16 | issue= 7 | pages= 1277-82 | pmid=12144577 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12144577  }} </ref><ref name="pmid10543364">{{cite journal| author=Ali BH| title=Pharmacological, therapeutic and toxicological properties of furazolidone: some recent research. | journal=Vet Res Commun | year= 1999 | volume= 23 | issue= 6 | pages= 343-60 | pmid=10543364 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10543364  }} </ref><ref name="pmid11929398">{{cite journal| author=Wong WM, Wong BC, Lu H, Gu Q, Yin Y, Wang WH et al.| title=One-week omeprazole, furazolidone and amoxicillin rescue therapy after failure of Helicobacter pylori eradication with standard triple therapies. | journal=Aliment Pharmacol Ther | year= 2002 | volume= 16 | issue= 4 | pages= 793-8 | pmid=11929398 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11929398  }} </ref>
*Not currently used in the United states
*Side effects include [[nausea]], [[vomiting]], headache and malaise
'''Levofloxacin'''
*[[Levofloxacin]]-based triple therapy ([[proton pump inhibitor|PPI]], [[levofloxacin]], and [[amoxicillin]]) can be used as second and third-line therapy in patients with persistent ''[[H. pylori]]'' infection.<ref name="pmid16542284">{{cite journal| author=Saad RJ, Schoenfeld P, Kim HM, Chey WD| title=Levofloxacin-based triple therapy versus bismuth-based quadruple therapy for persistent Helicobacter pylori infection: a meta-analysis. | journal=Am J Gastroenterol | year= 2006 | volume= 101 | issue= 3 | pages= 488-96 | pmid=16542284 | doi=10.1111/j.1572-0241.1998.455_t.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16542284  }} </ref><ref name="pmid16393278">{{cite journal| author=Gisbert JP, Morena F| title=Systematic review and meta-analysis: levofloxacin-based rescue regimens after Helicobacter pylori treatment failure. | journal=Aliment Pharmacol Ther | year= 2006 | volume= 23 | issue= 1 | pages= 35-44 | pmid=16393278 | doi=10.1111/j.1365-2036.2006.02737.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16393278  }} </ref><ref name="pmid16454825">{{cite journal| author=Gisbert JP, Castro-Fernández M, Bermejo F, Pérez-Aisa A, Ducons J, Fernández-Bermejo M et al.| title=Third-line rescue therapy with levofloxacin after two H. pylori treatment failures. | journal=Am J Gastroenterol | year= 2006 | volume= 101 | issue= 2 | pages= 243-7 | pmid=16454825 | doi=10.1111/j.1572-0241.2006.00457.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16454825  }} </ref>
==H.pylori Treatment Options in Developing Countries==
''[[H. pylori]]'' treatment options in developing countries include:<ref name="pmid21961099">{{cite journal| author=Hunt RH, Xiao SD, Megraud F, Leon-Barua R, Bazzoli F, van der Merwe S et al.| title=Helicobacter pylori in developing countries. World Gastroenterology Organisation Global Guideline. | journal=J Gastrointestin Liver Dis | year= 2011 | volume= 20 | issue= 3 | pages= 299-304 | pmid=21961099 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21961099  }} </ref>
{| class="wikitable"
! colspan="2" style="background:#4479BA; color: #FFFFFF;" + | First-Line therapies
|-
| style="background:#DCDCDC; + " | [[Proton pump inhibitor|PPI]] + [[amoxicillin]] + [[clarithromycin]]
(All twice daily for 7 days)
|
* Used and accepted throughout the world
* Eradication rates have fallen to 70-85% over the last few years, in part due to increasing resistance to [[clarithromycin]]
* Cost considerations and compliance issues may favor 7-days therapy
* Some groups suggest treatment for 10 or 14 days
* Other inexpensive [[macrolides]], such as [[azithromycin]], are available over the counter in developing countries, and [[macrolide]] cross-resistance affects eradication rate
|-
| style="background:#DCDCDC; + " | In case of a [[clarithromycin]] resistance rate of more than 20%:
Quadruple therapy: [[Proton pump inhibitor|PPI]] b.i.d. + [[bismuth]] + [[tetracycline]] + [[metronidazole]] all q.i.d. for 7 - 10 days
|
* May be cheaper than triple therapy
* More difficult to take than triple therapy. A single triple capsule has been shown to facilitate its use
* Equivalent eradication rates in comparison with standard triple therapy
* In vitro [[metronidazole]] resistance may be overcome by prolonging therapy or using high doses of [[metronidazole]]
|-
| colspan="2" |If there is no known [[clarithromycin]] resistance or [[clarithromycin]] resistance is not likely:
* [[Proton pump inhibitor|PPI]] + [[amoxicillin]] + [[clarithromycin]] for 7 days
* Quadruple therapy: PPI + bismuth + tetracycline + metronidazole for 7-10 days
* If bismuth not available: concomitant therapy: [[Proton pump inhibitor|PPI]] + [[clarithromycin]] + [[metronidazole]] + [[amoxicillin]] for 14 days
* [[Furazolidone]]-containing regimens: [[Proton pump inhibitor|PPI]] + [[furazolidone]] + antibiotic is slightly less effective than the standard triple regimens
* Furazolidone can replace amoxicillin in standard triple therapy
* Sequential regimen: 10-day therapy with PPI + amoxicillin for 5 days followed by PPI + clarithromycin and a nitroimidazole (tinidazole) for 5 days
|-
! colspan="2" style="background:#4479BA; color: #FFFFFF;" + | Second-line therapies, after failure of clarithromycin incontaining regimens
|-
| colspan="2" |
* PPI + bismuth + tetracycline + metronidazole for 10-14 days
* PPI + amoxicillin + levofloxacin for 10 days
* PPI + furazolidone + tetracycline + bismuth for 10 days
* PPI + furazolidone + levofloxacine for 10 days
* PPI + amoxicillin + clarithromycin for 7 days
* PPI + amoxicillin + levofloxacin for 10 days
* PPI + furazolidone + levofloxacin for 10 days
|-
! colspan="2" style="background:#4479BA; color: #FFFFFF;" + | Third-line therapies, after failure of clarithromycin-containing regimens and quadruple therapy
|
|-
| colspan="2" |
* PPI + amoxicillin + levofloxacin for 10 days
* PPI + amoxicillin + rifabutin for 10 days
* PPI + furazolidone + levofloxacin for 7-10 days
|}
:*B.i.d (twice a day); q.i.d (four times a day); PPI, proton-pump inhibitor
==Testing to Prove Eradication After Antibiotic Therapy==
The following are the indications for testing to prove eradication after antibiotic therapy.<ref name="pmid10840297">{{cite journal| author=Laine L, Sugg J, Suchower L, Neil G| title=Endoscopic biopsy requirements for post-treatment diagnosis of Helicobacter pylori. | journal=Gastrointest Endosc | year= 2000 | volume= 51 | issue= 6 | pages= 664-9 | pmid=10840297 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10840297  }} </ref>
*Any patient with an H.pylori-associated ulcer
*Individuals with persistent dyspeptic symptoms despite the test-and-treat strategy
*Those with H.pylori associated MALT lymphoma
*Individuals who have undergone resection of early gastric cancer
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
​​
{{WH}}
{{WS}}


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Aravind Reddy Kothagadi M.B.B.S[2]

Overview

Medical therapy for Gastritis depends on its specific cause. Medications known to cause gastritis such as NSAIDs (aspirin, naproxen, ibuprofen) should be discontinued. Smoking cessation and abstinence from alcohol consumption is recommended. Medications to decrease gastric acid production such as proton pump inhibitors (PPI) are recommended. In cases of Helicobacter pylori infection, antimicrobial drugs are recommended. Helicobacter infection typically responds well to the triple therapy protocol (consisting of two antibiotics, and a proton pump inhibitor). Regimens that work well include PCA or PCM triple therapy (PPI, Clarithromycin, Amoxicillin) or (PPI, clarithromycin, Metronidazole). Quadruple therapy has a >90% success rate and includes PPIs, bismuth subsalicylates, metronidazole, and tetracycline. Indications for treatment of H. pylori infection include past or present duodenal and/or gastric ulcer, with or without complications, following resection of gastric cancer, gastric mucosa-associated lymphoid tissue (MALT) lymphoma, atrophic gastritis, dyspepsia, patients with first-degree relatives with gastric cancer and patient‘s wishes. Factors involved in choosing treatment regimens include prevalence of H. pylori infection, prevalence of gastric cancer, resistance to antibiotics, availability of bismuth, availability of endoscopy and H. pylori tests, ethnicity, drug allergies and tolerance, previous treatments and outcome, adverse effects, effectiveness of local treatment and recommended dosages and treatment duration.

Medical Therapy

Medical therapy for gastritis depends on its specific cause.

Factors involved in choosing treatment regimens include:[1]

  • Prevalence of H. pylori infection
  • Prevalence of gastric cancer
  • Resistance to antibiotics
  • Availability of bismuth
  • Cost of tests
  • Availability of endoscopy and H. pylori tests
  • Ethnicity
  • Drug allergies and tolerance
  • Previous treatments and outcome
  • Ease of administration
  • Adverse effects
  • Effectiveness of local treatment
  • Recommended dosages and treatment duration

First-Line Regimens for Helicobacter pylori Eradication

Regimen Duration Eradication rates Comments
Standard dose PPI b.i.d. (esomeprazole is q.d.),

clarithromycin 500 mg b.i.d., amoxicillin 1,000 mg b.i.d.

10–14 70–85% Consider in nonpenicillin allergic patients who have not previously received a macrolide
Standard dose PPI b.i.d., clarithromycin 500 mg b.i.d.

metronidazole 500 mg b.i.d.

10–14 70–85% Consider in penicillin allergic patients who have not previously received a macrolide or are unable to tolerate bismuth quadruple therapy
Bismuth subsalicylate 525 mg p.o. q.i.d. metronidazole

250 mg p.o. q.i.d., tetracycline 500 mg p.o. q.i.d.,

ranitidine 150 mg p.o. b.i.d. or standard dose

PPI q.d. to b.i.d.

10–14 75–90% Consider in penicillin allergic patients
PPI + amoxicillin 1 g b.i.d. followed by

PPI, clarithromycin 500 mg, tinidazole 500 mg b.i.d.

5

5

>90% Requires validation in North America
PPI = proton pump inhibitor; pcn = penicillin; p.o. = orally; q.d. = daily; b.i.d. = twice daily; t.i.d. = three times daily; q.i.d. = four times daily.

*Standard dosages for PPIs are as follows:

lansoprazole 30 mg p.o., omeprazole 20 mg p.o., pantoprazole 40 mg p.o., rabeprazole 20 mg p.o., esomeprazole 40 mg p.o.

Note: the above-recommended treatments are not all FDA approved.


FDA approved regimens are as follows:

1. Bismuth 525 mg q.i.d. + metronidazole 250 mg q.i.d. + tetracycline 500 mg q.i.d. × 2 wk + H2RA as directed × 4 wk.

2. Lansoprazole 30 mg b.i.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 10 days.

3. Omeprazole 20 mg b.i.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 10 days.

4. esomeprazole 40 mg q.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 10 days.

5. Rabeprazole 20 mg b.i.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 7 days.

Predictors of H.pylori Treatment Outcome

Predictors of treatment failure include:

  • Poor compliance
  • Antibiotic resistance (key factor in the failure of eradication therapy and recurrence of H. pylori infection)
  • Bacterial factors like CagA-negative strains are at increased risk of treatment failure compared with CagA-positive strains
  • CYP2C 19 polymorphisms may influence treatment outcomes when regimens containing PPIs are used as they influence the clearance of PPIs and thus their effect on gastric acid secretion.
Drugs Side effects Recommendations
Proton pump inhibitors (PPIs) PPIs should be taken 30-60 min before eating to optimize their effects on gastric acid secretion.
Clarithromycin
  • GI upset
  • Headache
  • Altered taste
Amoxicillin
Metronidazole
  • Metallic taste in the mouth
  • Dyspepsia
  • A disulfiram-like reaction with alcohol consumption
Tetracycline Tetracyclinhes should not be given to children under 8 yr of age because of possible tooth discoloration
Bismuth Compounds
  • Darkening of tongue and stool
  • Nausea
  • GI upset

Salvage Therapy for Persistent H.pylori Infection

  • In patients with persistent H. pylori infection, every effort should be made to avoid antibiotics that have been previously taken by the patient.[2]
  • Bismuth-based quadruple therapy for 7-14 days is an accepted salvage therapy.
  • Levofloxacin-based triple therapy for 10 days is another option in patients with persistent infection, which requires validation in the United States.
Regimen Duration Eradication rates Comments
Bismuth quadruple therapy

PPI q.d. tetracycline, Pepto Bismol, metronidazole q.i.d.

7 68% Accessible, cheap but high pill count, and frequent mild side effects
Levofloxacin triple therapy

PPI, amoxicillin 1 g b.i.d., levofloxacin 500 mg q.d.

10 10 87% Requires validation in North America
  • Triple therapy should be used if a patient has persistent infection who has previously not been treated with clarithromycin.
  • In patients who were treated with clarithromycin initially, bismuth quadruple therapy is used as salvage therapy.

Other Alternative Antibiotics

Rifabutin

Furazolindone

Levofloxacin

H.pylori Treatment Options in Developing Countries

H. pylori treatment options in developing countries include:[1]

First-Line therapies
PPI + amoxicillin + clarithromycin

(All twice daily for 7 days)

  • Used and accepted throughout the world
  • Eradication rates have fallen to 70-85% over the last few years, in part due to increasing resistance to clarithromycin
  • Cost considerations and compliance issues may favor 7-days therapy
  • Some groups suggest treatment for 10 or 14 days
  • Other inexpensive macrolides, such as azithromycin, are available over the counter in developing countries, and macrolide cross-resistance affects eradication rate
In case of a clarithromycin resistance rate of more than 20%:

Quadruple therapy: PPI b.i.d. + bismuth + tetracycline + metronidazole all q.i.d. for 7 - 10 days

  • May be cheaper than triple therapy
  • More difficult to take than triple therapy. A single triple capsule has been shown to facilitate its use
  • Equivalent eradication rates in comparison with standard triple therapy
  • In vitro metronidazole resistance may be overcome by prolonging therapy or using high doses of metronidazole
If there is no known clarithromycin resistance or clarithromycin resistance is not likely:
  • PPI + amoxicillin + clarithromycin for 7 days
  • Quadruple therapy: PPI + bismuth + tetracycline + metronidazole for 7-10 days
  • If bismuth not available: concomitant therapy: PPI + clarithromycin + metronidazole + amoxicillin for 14 days
  • Furazolidone-containing regimens: PPI + furazolidone + antibiotic is slightly less effective than the standard triple regimens
  • Furazolidone can replace amoxicillin in standard triple therapy
  • Sequential regimen: 10-day therapy with PPI + amoxicillin for 5 days followed by PPI + clarithromycin and a nitroimidazole (tinidazole) for 5 days
Second-line therapies, after failure of clarithromycin incontaining regimens
  • PPI + bismuth + tetracycline + metronidazole for 10-14 days
  • PPI + amoxicillin + levofloxacin for 10 days
  • PPI + furazolidone + tetracycline + bismuth for 10 days
  • PPI + furazolidone + levofloxacine for 10 days
  • PPI + amoxicillin + clarithromycin for 7 days
  • PPI + amoxicillin + levofloxacin for 10 days
  • PPI + furazolidone + levofloxacin for 10 days
Third-line therapies, after failure of clarithromycin-containing regimens and quadruple therapy
  • PPI + amoxicillin + levofloxacin for 10 days
  • PPI + amoxicillin + rifabutin for 10 days
  • PPI + furazolidone + levofloxacin for 7-10 days
  • B.i.d (twice a day); q.i.d (four times a day); PPI, proton-pump inhibitor

Testing to Prove Eradication After Antibiotic Therapy

The following are the indications for testing to prove eradication after antibiotic therapy.[13]

  • Any patient with an H.pylori-associated ulcer
  • Individuals with persistent dyspeptic symptoms despite the test-and-treat strategy
  • Those with H.pylori associated MALT lymphoma
  • Individuals who have undergone resection of early gastric cancer

References

  1. 1.0 1.1 1.2 Hunt RH, Xiao SD, Megraud F, Leon-Barua R, Bazzoli F, van der Merwe S; et al. (2011). "Helicobacter pylori in developing countries. World Gastroenterology Organisation Global Guideline". J Gastrointestin Liver Dis. 20 (3): 299–304. PMID 21961099.
  2. 2.0 2.1 Isakov V, Domareva I, Koudryavtseva L, Maev I, Ganskaya Z (2002). "Furazolidone-based triple 'rescue therapy' vs. quadruple 'rescue therapy' for the eradication of Helicobacter pylori resistant to metronidazole". Aliment Pharmacol Ther. 16 (7): 1277–82. PMID 12144577.
  3. Miehlke S, Hansky K, Schneider-Brachert W, Kirsch C, Morgner A, Madisch A; et al. (2006). "Randomized trial of rifabutin-based triple therapy and high-dose dual therapy for rescue treatment of Helicobacter pylori resistant to both metronidazole and clarithromycin". Aliment Pharmacol Ther. 24 (2): 395–403. doi:10.1111/j.1365-2036.2006.02993.x. PMID 16842467.
  4. Perri F, Festa V, Clemente R, Villani MR, Quitadamo M, Caruso N; et al. (2001). "Randomized study of two "rescue" therapies for Helicobacter pylori-infected patients after failure of standard triple therapies". Am J Gastroenterol. 96 (1): 58–62. doi:10.1111/j.1572-0241.2001.03452.x. PMID 11197288.
  5. Bock H, Koop H, Lehn N, Heep M (2000). "Rifabutin-based triple therapy after failure of Helicobacter pylori eradication treatment: preliminary experience". J Clin Gastroenterol. 31 (3): 222–5. PMID 11034001.
  6. Wong WM, Gu Q, Lam SK, Fung FM, Lai KC, Hu WH; et al. (2003). "Randomized controlled study of rabeprazole, levofloxacin and rifabutin triple therapy vs. quadruple therapy as second-line treatment for Helicobacter pylori infection". Aliment Pharmacol Ther. 17 (4): 553–60. PMID 12622764.
  7. Borody TJ, Pang G, Wettstein AR, Clancy R, Herdman K, Surace R; et al. (2006). "Efficacy and safety of rifabutin-containing 'rescue therapy' for resistant Helicobacter pylori infection". Aliment Pharmacol Ther. 23 (4): 481–8. doi:10.1111/j.1365-2036.2006.02793.x. PMID 16441468.
  8. Ali BH (1999). "Pharmacological, therapeutic and toxicological properties of furazolidone: some recent research". Vet Res Commun. 23 (6): 343–60. PMID 10543364.
  9. Wong WM, Wong BC, Lu H, Gu Q, Yin Y, Wang WH; et al. (2002). "One-week omeprazole, furazolidone and amoxicillin rescue therapy after failure of Helicobacter pylori eradication with standard triple therapies". Aliment Pharmacol Ther. 16 (4): 793–8. PMID 11929398.
  10. Saad RJ, Schoenfeld P, Kim HM, Chey WD (2006). "Levofloxacin-based triple therapy versus bismuth-based quadruple therapy for persistent Helicobacter pylori infection: a meta-analysis". Am J Gastroenterol. 101 (3): 488–96. doi:10.1111/j.1572-0241.1998.455_t.x. PMID 16542284.
  11. Gisbert JP, Morena F (2006). "Systematic review and meta-analysis: levofloxacin-based rescue regimens after Helicobacter pylori treatment failure". Aliment Pharmacol Ther. 23 (1): 35–44. doi:10.1111/j.1365-2036.2006.02737.x. PMID 16393278.
  12. Gisbert JP, Castro-Fernández M, Bermejo F, Pérez-Aisa A, Ducons J, Fernández-Bermejo M; et al. (2006). "Third-line rescue therapy with levofloxacin after two H. pylori treatment failures". Am J Gastroenterol. 101 (2): 243–7. doi:10.1111/j.1572-0241.2006.00457.x. PMID 16454825.
  13. Laine L, Sugg J, Suchower L, Neil G (2000). "Endoscopic biopsy requirements for post-treatment diagnosis of Helicobacter pylori". Gastrointest Endosc. 51 (6): 664–9. PMID 10840297.

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