3. HELICOBACTER PYLORI Millions of years old microorganism of mankind Causes a spectrum of diseases Obviously requires high priority Treatment strategies to be evolved to eradicate the microorganism

4. Goal of Treatment Single point agenda Eradication of Helicobacter pylori  from the individual  from the family  from the community and  from the world

5. WHY SHOULD WE ERADICATE H PYLORI? Reduces the risk of peptic ulcer disease recurrence Regression of low grade MALT and gastric B cell lymphoma Chemo preventive benefit for gastric adenocarcinoma Reduction in morbidity and mortality

6. WHO SHOULD RECEIVE THERAPY? Helicobacter pylori proven Peptic ulcer disease Gastritis – controversial Patients (and the relatives of patients?)with gastric cancer MALT Reflux oesophagitis

7. WHO SHOULD NOT RECEIVE THERAPY? Asymptomatic H. pylori infection Non ulcer dyspepsia Recurrent abdominal pain H. pylori positive children Children at increased risk of acquisition of infection Patients taking NSAIDs

8. THE SELECTION CRITERIA 5 points Target: : Minimum 80 % cure Number one Single drug regimens – Ineffective Combination therapy- highest result Two or three antibiotics plus acid suppressive

9. THE SELECTION CRITERIA Number two Proton pump inhibitor or H 2 receptor antagonist - enhances the effectiveness Number three 10-14 days treatment regimens are superior to shorter courses

10. THE SELECTION CRITERIA Number Four Poor patient compliance - linked to the medication related side effects Packaging that combines the daily doses into one convenient is available Number Five Problem of resistance

11. WITH WHAT TO TREAT? Antimicrobial agents Acid reducing agents and / or Mucosal protectives

12. MANAGEMENT OBJECTIVES  To relieve pain  To eliminate the need of maintenance therapy  To prevent recurrence  To prevent complications of disease  To prevent drug resistance

13. Too many regimens! First line regimen: Triple drug therapy –Twice daily for 14 days 1. O meprazole 20mg 2 cap A moxicillin 750mg 2 tab C larithromycin 250 mg 2 tab TREATMENT REGIMEN

14. 2. Lansoprazole 30 mg 2 cap Amoxicillin 750 mg 2 tab Tinidazole 500 mg 2 tab 3. Lansoprazole 30 mg 2 cap Clarithromycin 250 mg 2 tab Amoxicillin 750 mg 2 tab TOO MANY REGIMENS!

15. 4. Lanzoprazole Tinidazole Clarithromycin 5. Lansoprazole Amoxicillin Clarithromycin 6. Amoxicillin Metronidazole Ranitidine 30 mg 2 cap 500mg 2 tab 250mg 2 cap 30mg bid 1000mg bid 500mg bid 750mg tid 500mg tid 300mg qd

16. Treatment Regimen Second line regimen: Bismuth based quadruple therapy-7 days 1. Bismuth subsalicylate120mg qid Metronidazole 500 mg tid Tetracycline 500 mg qid PPI standard dose bid

17. Treatment Regimen 2. Levofloxacin 500 mg qid Amoxicillin 1000mg bid PPI standard dose bid for 10 days

18. Treatment Regimen Alternative regimen - 10 to14 days 1. Rifabutin 300mg qid Amoxicillin 1000mg bid PPI standard dose bid 2. Furazolidone 100 mg bid Amoxicillin 1000mg bid PPI standard dose bid

19. Treatment Regimen Sequential therapy: 10 days 5 days of PPI and Amoxicillin followed by an additional 5 days of PPI, Clarithromycin and Tinidazole

20. GENERAL MEASURES Stop smoking Patients with peptic ulcer: continue PPI for 3-4 weeks Symptomatically assess the effectiveness of the treatment

21. SUCCESS OR FAILURE? SUCCESS OR FAILURE? Follow up with investigations is required: If symptoms persist Patients with complications Patients with gastric ulcer

22. PROBLEMS TO BE TACKLED! 1. Non compliance 2. Side effects 3. Antimicrobial resistance

23. PROBLEMS TO BE TACKLED! 1.Non compliance Factors influencing: Duration of therapy Complexity of treatment regimen Frequency and severity of side effects

24. PROBLEMS TO BE TACKLED 2. Side effects Proton Pump Inhibitors Headache and diarrhoea May occur in 10% Clarithromycin GI upset - Diarrhoea Altered taste

25. PROBLEMS TO BE TACKLED Amoxicillin GI upset - Diarrhoea Headache Metronidazole Largely dose related Metallic taste - Dyspepsia Disulfiram – like reactions with alcohol

26. PROBLEMS TO BE TACKLED Tetracycline  GI upset  Photosensitivity  Contraindicated Children < 8 year Pregnancy and Lactation

27. PROBLEMS TO BE TACKLED Bismuth compounds Blackening of tongue Blackening of stool Nausea GI upset

28. PROBLEMS TO BE TACKLED 3. Antimicrobial resistance  Maximum for Clarithromycin and Metronidazole  Varies by geographical region  Increased by prior use for infection

29. PROBLEMS TO BE TACKLED! Clarithromycin - All or none - Related to mutations Metronidazole Relative and not absolute Higher dose or addition of another agent Bacterial adaptations