Pearls of Wisdom: H pylori Infection
Question: John is a 32-year-old homeless man who had recently been admitted for upper gastrointestinal bleeding. He was diagnosed with gastritis, related to a combination of risk factors including excessive alcohol. His gastric biopsy was also positive for Helicobacter pylori.
John failed to adhere to advice on smoking cessation and alcohol intake reduction. Furthermore, he was low on funds and did not purchase any of the regimen prescribed to treat his H pylori infection.
Which regimen below might be both effective and affordable to our patient with marginal resources and a tendency to have a short attention span for compliance?
A. Traditional 10-day treatment: proton pump inhibitors (omeprazole 20 mg or lansoprazole 30 mg) + amoxicillin 1 g +
clarithromycin 500 mg twice a day.
B. Traditional 14 to 28-day treatment: bismuth subsalicylate 525 mg + metronidazole 250 mg + tetracycline 500 mg 4 times a day
for 2 weeks, in addition to H2 receptor antagonist for 4 weeks.
C. One-day quadruple therapy.
What is the correct answer?
(Answer and discussion on next page)
Louis Kuritzky, MD, has been involved in medical education since the 1970s. Drawing upon years of clinical experience, he has crafted each year for almost 3 decades a collection of items that are often underappreciated by clinicians, yet important for patients. His “Pearls of Wisdom” as we like to call them, have been shared with primary care physicians annually in an educational presentation entitled 5TIWIKLY (“5 Things I Wish I Knew Last Year”…. or the grammatically correct, “5 Things I Wish I’d Known Last Year”).
Now, for the first time, Dr Kuritzky is sharing with the Consultant360 audience. Sign up today to receive new advice each week.
Answer: One-day quadruple therapy.
Isn’t there a certain basic sensibility to the philosophy, “Just give the best treatment you can!” After all, there are best treatments that patients decline, best treatments that are not available in your particular setting, best treatments of some urgency that are not available with immediacy, best treatments not covered by the patients insurance, best treatments the patient cannot afford, etc. We have a patient who would benefit from eradication of H pylori, but his past history and current situation provide 2 challenges: chronic noncompliance and limited economic resources. How can we navigate these obstacles?
What is the Best Treatment?
The first stepis to recognize that guideline-advocated first choice treatments are often not the only treatment. For example, the CDC has long advocated treatment for bacterial vaginosis with metronidazole 500 mg twice a day for 7 days over the much more convenient 2 g single dose.
Differences in efficacy between these 2 regimens are very small. Generally, when I encounter a BV patient, I advise her that the CDC recommends the more stringent course, but that the single dose is also highly effective. Additionally, if the patient falls into the small group of folks for whom the single 2 g dose fails, we can always follow-up with the weeklong course. So, I’d always be willing to try the shorter—albeit minimally less effective—course first.
This doesn’t even factor in that many patients will be noncompliant with the full 7-day regimen, and may end up achieving lower efficacy because of deficits in compliance.
I like the language used in the American Cancer Society’s recent colon cancer screening guidelines: the best screening test for colon cancer is the one you can get done! Sure, we’d rather have everybody signed up for well-timed colonscopies, but it is apparent that John Q Public is not always willing to meet us there. Instead, it’s better to get a lesser sensitive screening test done than no test at all.
So, back to our Helicobacter patient. We know he has Helicobacter, that he is noncompliant, and that he has minimal economic resources. Is there any other choice besides traditional long-term complex regimens?
H Pylori: One-Day Quadruple Therapy1
A 2003 study1 compared patients in a 1-day regimen (bismuth subsalicylate 534 mg QID + metronidazole 500 mg QID + amoxicillin suspension 2 g QID + lansoprazole 60 mg 1 dose) with a traditional weeklong regimen (clarithromycin 500 mg BID for 7 days + amoxicillin 1 g BID for 7 days + lansoprazole 30 mg BID for 7 days) in 160 H pylori positive patients. The outcomes were essentially the same.
1-Day vs. 7-Day H Pylori Treatment1
What’s the “Take Home”?
Between the two poles of “best therapy” and “worst therapy,” there are almost always considerations that might be labelled “acceptable therapy.” When factors beyond our control make “best therapy” inaccessible, it’s worth considering novel approaches that have been literature-substantiated, even though such approaches may not have achieved the status of guideline advocacy.
1. Lara L, Cisneros G, Gurney M, et al. One-day quadruple therapy compared with 7-day triple therapy for Helicobacter pylori infection. Arch Intern Med. 2003;163(17):2079-2084.