page70
and
either
amoxicillin
or
metronidazole can be used.
However,
if
a patient has been treated with metronid-
azole for other infections, a regimen containing a proton
pump inhibitor,
amoxicillin and clarithromycin is pre-
ferred for initial
therapy.
If
a patient has been treated
with a macrolide for other infections, a regimen contain-
ing a proton pump inhibitor,
amoxicillin and metronid-
azole is preferred for
initial
therapy.
These regimens
eradicate
H.
pylori
in about
85% of
cases.
There is
usually no need to continue antisecretory treatment
(with a proton pump inhibitor or H
2
-receptor antago-
nist),
however,
if
the ulcer is large,
or complicated by
haemorrhage or
perforation,
then antisecretory treat-
ment
is continued for
a further
3 weeks.
Treatment
failure
usually
indicates
antibacterial
resistance
or
poor compliance. Resistance to amoxicillin is rare. How-
ever,
resistance to clarithromycin and metronidazole is
common and can develop during treatment.
Two-week triple-therapy regimens offer the possibility
of higher eradication rates compared to one-week regi-
mens,
but adverse effects are common and poor com-
pliance is likely to offset any possible gain.
Two-week dual-therapy regimens using a proton pump
inhibitor
and a single antibacterial
are licensed,
but
produce low rates of
H. pylori
eradication and are not
recommended.
Tinidazole is also used occasionally for
H. pylori
eradi-
cation as
an alternative to metronidazole;
tinidazole
should be
combined with antisecretory
drugs
and
other antibacterials.
A two-week regimen comprising a proton pump inhibi-
tor (e.g.
omeprazole 20 mg twice daily)
plus
tripotass-
ium dicitratobismuthate 120 mg four times daily,
plus
tetracycline 500 mg four times daily,
plus
metronidazole
400–500 mg three times daily can be used for eradica-
tion failure. Alternatively, the patient can be referred for
endoscopy and treatment based on the results of culture
and sensitivity testing.
For the role of
H. pylori
eradication therapy in patients
starting
or
taking
a
NSAID,
see
NSAID-associated
Ulcers,
below.
For
H.
pylori
eradication in patients
with dyspepsia,
see also section 1.1.
Test for Helicobacter pylori
13
C-Urea breath test kits are available for the diagnosis
of
gastro-duodenal
infection with
Helicobacter pylori
.
The test
involves collection of
breath samples before
and after ingestion of
an oral
solution of
13
C-urea;
the
samples are sent for analysis by an appropriate labora-
tory. The test should not be performed within 4 weeks of
treatment
with an antibacterial
or
within 2 weeks of
treatment
with an antisecretory drug.
A specific
13
C-
urea breath test
kit
for
children is available (
Helico-
bacter
Test
INFAI
for
children of
the age 3–11
c
).
However,
the appropriateness of
testing for
H.
pylori
infection in children has not been established.
diabact UBT
c
(MDE) A
Tablets
,
13
C-urea 50 mg,
net price 1 kit (including 1
tablet,
4 breath-sample containers, straws) = £21.25
(analysis included),
10-kit pack (hosp.
only) = £74.50
(analysis not included)
Helicobacter Test INFAI
c
(Infai) A
Oral powder
,
13
C-urea 75 mg, net price 1 kit (including
4 breath-sample containers, straws) = £19.20 (spec-
trometric analysis included),
1 kit (including 2 breath
bags) = £14.20 (spectroscopic analysis not included),
50-test set = £855.00 (spectrometric analysis
included); 45 mg (
Helicobacter Test INFAI for chil-
dren of the age 3–11
c
),
1 kit (including 4 breath-
sample containers,
straws) = £19.20 (spectrometric
analysis included)
Pylobactell
c
(Torbet) A
Soluble tablets
,
13
C-urea 100 mg,
net price 1 kit
(including 6 breath-sample containers,
30-mL mixing
and administration vial,
straws) = £20.75 (analysis
included)
NSAID-associated ulcers
Gastro-intestinal bleeding and ulceration can occur with
NSAID use (section 10.1.1).
The risk of
serious upper
gastro-intestinal
side-effects varies between individual
NSAIDs (see CSM advice,
p.
632).
Whenever possible,
the NSAID should be withdrawn if an ulcer occurs.
Recommended regimens for Helicobacter pylori eradication in adults
Antibacterial
Price for 7-day course
Acid suppressant
Amoxicillin
Clarithromycin
Metronidazole
Esomeprazole
1 g twice daily
500 mg twice daily
—
£15.10
20 mg twice daily
—
250 mg twice daily
400 mg twice daily
£13.32
Lansoprazole
1 g twice daily
500 mg twice daily
—
£6.97
30 mg twice daily
1 g twice daily
—
400 mg twice daily
£3.77
—
250 mg twice daily
400 mg twice daily
£5.19
Omeprazole
1 g twice daily
500 mg twice daily
—
£6.81
20 mg twice daily
500 mg 3 times daily
—
400 mg 3 times daily
£3.62
—
250 mg twice daily
400 mg twice daily
£5.03
Pantoprazole
1 g twice daily
500 mg twice daily
—
£7.26
40 mg twice daily
—
250 mg twice daily
400 mg twice daily
£5.48
Rabeprazole
1 g twice daily
500 mg twice daily
—
£15.63
20 mg twice daily
—
250 mg twice daily
400 mg twice daily
£13.85
50
1.3 Antisecretory drugs and mucosal protectants
BNF 61
1
Gastro-intestinal system