ACG updates guideline for managing H. pylori in treatment-naive, experienced patients
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Key takeaways:
- Bismuth quadruple therapy is recommended as first-line treatment in treatment-naive patients.
- Optimized bismuth quadruple therapy is suggested in certain treatment-experienced patients with persistent infection.
The ACG has released a new clinical practice guideline that summarizes therapy options and recommendations for both treatment-naive and treatment-experienced patients with active Helicobacter pylori infection, as well as testing concerns.
“H. pylori remains one of the most common chronic bacterial infections of humans worldwide,” William D. Chey, MD, FACG, AGAF, FACP, RFF, H. Marvin Pollard Professor of Gastroenterology and chief of gastroenterology and hepatology at Michigan Medicine, and colleagues wrote in The American Journal of Gastroenterology. “It is the leading cause of infection-associated cancer globally and is categorized by the World Health Organization International Agency for Research on Cancer as a group I carcinogen due to its causal association with gastric cancer.”
They continued: “The primary purpose of this ACG clinical practice guideline is to provide practical, actionable advice on the treatment of H. pylori infection in North America.”
Using Grading of Recommendations, Assessment, Development and Evaluation methodology, Chey and colleagues evaluated options for treatment-naive and treatment-experienced patients and analyzed 11 population-intervention-comparison-outcome questions, from which 12 recommendations were generated. They also created six key concepts, in the absence of sufficient evidence or if the topic was not amenable to GRADE methodology.
Highlights from the guideline, which provides “substantial changes” to the 2017 version and also addresses who to test, the need for universal post-treatment test-of-cure and antibiotic susceptibility testing, include:
- Bismuth quadruple therapy is recommended as first-line treatment in treatment-naive patients.
- Rifabutin triple therapy or dual therapy with a potassium competitive acid blocker (PCAB) and amoxicillin are suggested as first-line treatment options in treatment-naive patients.
- PCAB-clarithromycin triple therapy is suggested over proton pump inhibitor-clarithromycin triple therapy in treatment-naive patients with unknown clarithromycin susceptibility.
- Concomitant therapy is not suggested over bismuth quadruple therapy in treatment-naive patients.
- Optimized bismuth quadruple therapy is suggested in treatment-experienced patients with persistent infection and no history with bismuth quadruple therapy, as well as in patients who previously received PPI-clarithromycin triple therapy.
- Rifabutin triple therapy is suggested in treatment-experienced patients with persistent infection and a history of bismuth quadruple therapy.
- Levofloxacin triple therapy is suggested in treatment-experienced patients with persistent infection, known levofloxacin-sensitive H. pylori strains and when optimized bismuth quadruple or rifabutin triple therapies are unavailable or previously were used.
- There is insufficient evidence to support probiotic therapy to improve the efficacy or tolerability of H. pylori eradication therapy.
“In preparing this clinical practice guideline, we identified key knowledge gaps in the management of patients diagnosed with H. pylori infection or at risk of harboring H. pylori infection in North America, specifically, and these should be acknowledged as research priorities,” Chey and colleagues wrote. “As we increasingly utilize antibiotic susceptibility testing in clinical practice, every effort should be made to develop a national registry to track H. pylori antibiotic resistance rates for commonly used antibiotics and local eradication success rates with specific treatment regimens.”
They continued: “Such information would help clinicians to make the most evidence-based treatment choices for their patients.”
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