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Dyspepsia - unidentified cause - Management
Which treatment is recommended for Helicobacter pylori?
- Prescribe a 7-day triple-therapy regimen with twice-daily dosing (see Table 1). Preferred regimens are:
- Amoxicillin 1 g plus clarithromycin 500 mg plus either lansoprazole 30 mg or omeprazole 20 mg (all taken twice daily), or
- Clarithromycin 250 mg plus metronidazole 400 mg plus either lansoprazole 30 mg or omeprazole 20 mg (all taken twice daily).
- Other proton pump inhibitors can be used, but they are considerably more expensive (see Table 1 for dose).
- Avoid amoxicillin-containing regimens for those with known or suspected penicillin allergy.
- Check for recent use of clarithromycin or metronidazole; this may promote resistance, resulting in eradication failure:
- For those recently treated with clarithromycin (up to one year) for any infection, choose a regimen containing amoxicillin and metronidazole.
- For those recently treated with metronidazole (up to one year) for any infection, choose a regimen containing amoxicillin and clarithromycin.
- For people who require a second course of eradication therapy, choose a regimen that does not include antibiotics given previously.
Clarification / Additional information
- Table 1 shows the options for triple therapy for eradication of Helicobacter pylori.
- The individual components must be prescribed separately, as no proprietary triple-therapy product is available. Both Heliclear® and Helimet® have been discontinued in the UK.
- For eradication failure, the British National Formulary recommends [BNF 55, 2008]:
- A 2-week regimen comprising a proton pump inhibitor plus tripotassium dicitratobismuthate (De-Noltab®) 240 mg twice daily, plus tetracycline 500 mg four times daily, plus metronidazole 400 mg three times daily.
- Alternatively, if the person has been referred for endoscopy, treatment will be based on the results of culture and sensitivity testing.
Table 1. Triple therapy using antibiotics and proton pump inhibitor (PPI) for Helicobacter pylori eradication.
Antibiotics | PPI |
|---|
Amoxicillin 1 g twice daily | Clarithromycin 500 mg twice daily or Metronidazole 400 mg twice daily | Esomeprazole 20 mg twice daily or Lansoprazole 30 mg twice daily or Omeprazole 20 mg twice daily or Pantoprazole 40 mg twice daily or Rabeprazole 20 mg twice daily |
Clarithromycin 250 mg twice daily | Metronidazole 400 mg twice daily |
|
Basis for recommendation
- These recommendations are based on those issued by the National Institute for Health and Clinical Excellence (NICE), the Health Protection Agency and the British National Formulary [NICE, 2005; BNF 55, 2008; HPA, 2008].
- NICE recommends both clarithromycin-amoxicillin-proton pump inhibitor (PPI) and clarithromycin-metronidazole-PPI regimens as valid first-line therapies. This is supported by the Health Protection Agency [HPA, 2008]:
- Eradication is effective in 80–85% of people. Evidence from randomized controlled trials found both regimens to be equally effective, and better than the amoxicillin-metronidazole-PPI regimen.
- Choice of PPI:
- NICE does not recommend any particular PPI for use in triple therapies [NICE, 2005].
- Little evidence is available to support the use of one PPI over another. Evidence from meta-analyses found omeprazole and lansoprazole to be equally effective and as effective as other PPIs.
- Omeprazole and lansoprazole are considerably cheaper than other PPIs and are therefore recommended by CKS.
- The recommendation to avoid antibiotics which have been recently used is based on advice issued by the British National Formulary [BNF 55, 2008] and by the NICE guidance development group [North of England Dyspepsia Guideline Development Group, 2004]. However, there is uncertainty regarding how long these antibiotics should be avoided if they have been previously used for other infections.
- The NICE guidance development group identified advice which states that 'GPs should not use clarithromycin or metronidazole if the person has received this for any infection in the past year, as monotherapy with these agents very readily lead to resistance' [North of England Dyspepsia Guideline Development Group, 2004].
- The BNF does not provide any information regarding how long these antibiotics should be avoided if they have been used for other infections [BNF 55, 2008].
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