Treating Helicobacter pylori

One of the most common treatment regimens used in the Institute is the treatment protocol for Helicobacter pylori. In both clinics at Kauvery and Kalyani hospitals, we have used these regimens effectively to treat large number of patients. I have written this blog for you to benefit from this treatment to the maximum.

We must remember that despite the number of studies, there is no optimal therapeutic regimen that has been defined. Any treatment regimen that is selected must be effective, but also should consider cost, side effects, and ease of administration. Cost considerations have led us to refine our prescriptions so that they do not pinch the pockets of our patients.

One of the interesting stories I have heard from my father is about the treatment of peptic ulcers in the 70s. When posted in Dindugul district hospital as a Leprosy officer in 1974, he narrated the story of a patient who was diagnosed to have peptic ulcer. This patient was under the treatment of the senior medical officer in the hospital. During one visit, the patient asked for tetracycline tablets for the treatment of his peptic ulcer. My father dismissed him as crazy and prescribed his antacids. The patient returned to the senior medical officer and took the tetracycline. When questioned the senior medical officer replied that the patient became better with tetracycline and dismissed this as some fad. The Nobel prize was thus missed. It is surprising that tetracycline still has almost nil resistance in the treatment of H.pylori.

Dr. Barry Marshall, Microbiologist,
University of Western Australia

Dr. Robin Warren, Royal Perth Hospital
devised the diagnostic test - the Urea breath test

What my father missed was picked up by a microbiologist and a pathologist in Australia and this discovery changed the way we treat peptic ulcer. Today, we don't prescribe diets to these patients. We treat them for an infection.

But are we free from issues? Far from it, we have a host of other issues to address which have added to the complexity of the treatment.

The most common regimens used in the Institute for H.pylori eradication are the triple therapy and the sequential therapy. We prescribe the medications in individual pills and not as a convenience packaging, as we found that the dose of the antibiotics given in these packages is not adequate or does not match the regimens studied for eradication.

Triple therapy — this regimen is considered to be the first line treatment in the eradication of this bacterium. As the name indicates, there are 3 medications that are a major part of this regimen. They are the proton pump inhibitor, which reduces the amount of acid in the stomach (Look for a name ending with ‘prazole’ like ome’prazole’, panto’prazole’), and 2 antibiotics, one of which is clarithromycin and the other may be amoxicillin or metronidazole. For patients with penicillin allergy, metronidazole will be used. Clarithromycin is the most expensive of these medications. The regimen is prescribed for a period of 14 days. A higher dose of PPI and a duration of treatment for 14 days has a modest increase in the eradication rates.

In India, we have little data on the resistance patterns in H.pylori treatment. Researchers at the Banaras Hindu University have highlighted the fact that metronidazole resistance is almost universal in India and Amoxicillin resistance is present in more that 60 % of the patients, but clarithromycin resistance is very low at  5 %. So our regimen is mostly based on this drug. The bitter taste of clarithromycin is difficult to tolerate for patients and this has led to the discontinuation of treatment in a few. Some of the therapies given at other hospitals have this antibiotic, but it is at inadequate doses (250 mg twice daily instead of 500 mg twice daily).

Triple therapy is costlier than sequential therapy as it involves the use of clarithromycin for 14 days (Rs. 140 x 14 days) and we have been forced to reconsider the treatment regimen due to cost. The total cost of the treatment including the endoscopy works out to be more than Rs. 5000, which is quite costly for the patient population we treat.

Our current treatment regimen is the sequential treatment,which involves prescribing the medications one set after the other. We use a clarithromycin based regimen for these patients, as the incidence of clarithromycin resistance is very low in our country. The sequential treatment is also cost effective as it involves the use of clarithromycin for 5 days only. We have modified the regimen slightly and the tolerance is good. This enables our patients to complete the regimen.

For patients who fail this treatment or unable to tolerate this, we use the LOAD regimen which is quinolone based. For some reasons unclear, our patients do well if tehy continue PPI for some time and we advice them to take these medicines for a period of 4 weeks.

H. pylori is treatable and may lead to control of peptic ulcer in most of the patients.