AGA issues new clinical practice updates on H. pylori
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The American Gastroenterological Association published a new clinical practice update on the management of refractory Helicobacter pylori.
“Even though only 1% to 3% of infected individuals will develop malignant complications, H. pylori accounts for 15% of the total cancer burden globally, with up to 89% of all gastric cancer attributable to H. pylori infection,” Shailja C. Shah, MD, MPH, gastroenterology section at VA San Diego Healthcare System in La Jolla, Calif., and colleagues wrote. “Current national and international guidelines provide limited guidance on how to approach factors other than H. pylori antibiotic resistance, which might also underlie eradication failure, such as host- and systems-related factors. Collectively, these issues contribute to persistent H. pylori infection.”
Shah and colleagues developed 11 best practice updates on the management of H. pylori after initial eradication failure including advice on regimen selection and consideration of patient factors that contribute to treatment efficacy.
Addressed among the updates from the AGA are:
- Complex eradication regimens may not be fully comprehended by patients; communicating the rationale for therapy, dosing instructions, expected adverse events and importance of therapy completion is important for successful adherence.
- Longer treatment durations lead to higher success rates and should be selected when appropriate to bolster eradication.
- A common cause of refractory H. pylori is antibiotic resistance, other contributing etiologies and prior antibiotic exposures should be explored.
- In those with a penicillin allergy, experts recommend allergy testing to potentially enable its use.
- Providers should conduct H. pylori susceptibility testing after two failed eradications with confirmed patient adherence to guide future regimens.
“When considering the major public health implications associated with persistent H. pylori infection with respect to disease and treatment-related complications and cost, there is a clear need to prioritize systematic approaches to improve rates of successful H. pylori eradication with the least number of therapeutic attempts,” Shah and colleagues concluded.
Perspective
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Refractory H. pylori infection is unfortunately becoming a common issue in practice, stemming from multifactorial issues highlighted eloquently in the most recent AGA clinical practice update. Complicating this issue is the relative paucity of high-quality evidence to guide personalized therapy in patients, which includes important information on antimicrobial resistance rates/strain diversity and genetic/host factors.
It is generally assumed that current clarithromycin resistance rates in the United States is around 15%. Given this, there is relatively high-failure rate with this regimen deemed initially as one of the first line therapies for H. pylori (and one of the “easier” treatment regimens that can be tolerated by patients in terms of both dosing schedule and GI side effects). Further, metronidazole resistance is also quite high, which puts a nice dent in yet another first line “quadruple” treatment regimen taken with bismuth and tetracycline. This may potentially be somewhat overcome with an increase in dosing (1.5-2 g daily), but the GI side effects for many may be too difficult to adhere to (such as dysgeusia, nausea, and vomiting). There are other “salvage” therapies and variations of the above treatment theme; however, multiple regimens have, as of yet, limited data for routine use.
Although the consensus to treat H. pylori is based on global burden of H. pylori related malignancy (89% of gastric cancers, despite overall low risk for malignant transformation in those infected), the decision to treat, or re-treat – as with any medical treatment – should be very carefully weighed for each individual. Patients – especially those who are elderly with multiple comorbidities, frequent infections requiring repeated antibiotic therapy (including history of/or recurrent CDIs), multiple medication intolerances/allergies and advanced malignancies – can likely forgo treatment in the absence of complications (ie, peptic ulcer disease). I find patient compliance and tolerance as a major issue with eradication; if combined single pill therapies were readily available and covered by insurance, it could significantly aid with clearing this hurdle. Ongoing studies are needed to truly clarify individual malignancy risk for those chronically infected, including transmissibility, so that we use antibiotic resources in the wisest manner in the setting of alarming resistance patterns worldwide.
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