ACG guideline expands indications for H. pylori testing, treatment
The ACG has released new, updated guideline recommendations on the treatment of Helicobacter pylori infection in North America, based on the latest international data and expert consensus.
“After 2 years of work, we are proud of the guideline which we hope will help health care providers to better care for their patients with H. pylori infection,” William D. Chey, MD, FACG, of the division of gastroenterology, University of Michigan Health System, told Healio Gastroenterology.
William D. Chey
Significant advances have been made in the management of H. pylori infection since the last ACG guideline in 2007, especially in medical treatment, Chey and colleagues wrote. They therefore developed the new guideline based on literature published up to September 2014, and used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to determine the strength of each recommendation based on the quality of available evidence.
“The key highlights of the document include the expansion of indications to test for and treat H. pylori infection beyond just peptic ulcer disease, dyspepsia, functional dyspepsia, early gastric cancer and mucosa associated lymphoid tissue lymphoma to now also include selected patients taking aspirin or NSAIDs, unexplained iron deficiency anemia, and idiopathic thrombocytopenic purpura,” Chey said.
While patients with GERD symptoms with no history of peptic ulcer disease do not need to be tested for H. pylori infection, the guideline strongly recommends that those who do test positive should be offered treatment and informed that the effects on GERD symptoms are unpredictable.
“The document also emphasizes the importance of asking about previous antibiotic exposure when deciding upon the best treatment regimen for an individual patient,” Chey said. “Readers will note the decreasing role of first line triple therapy with a PPI, clarithromycin, and amoxicillin and the increased emphasis on varying forms of quadruple therapies.”
The guideline recommends that clarithromycin triple therapy should be avoided in regions where clarithromycin resistance is greater than 15% and in patients with prior exposure to macrolide, for instance.
“We also provide a detailed review of the best salvage regimens to use in North America when patients have persistent infection despite previous antibiotic therapy for H. pylori,” Chey said. Among them, bismuth quadruple therapy or levofloxacin salvage regimens are preferred in patients who received first-line clarithromycin, while clarithromycin- or levofloxacin-containing salvage regimens are preferred in patients who received first-line bismuth quadruple therapy. However, the guideline recommended that the best salvage regimens should be chosen based on local antimicrobial resistance data and the patient’s prior antibiotic exposure. In addition, the 2007 guideline recommendation that previously taken antibiotics should be avoided if possible in patients with persistent H. pylori infection was unchanged in the updated version.
“We hope that the algorithms in the guideline for selecting first line or salvage therapy will provide a practical road map which helps health care providers pick the right regimen for the right patient,” Chey said.
Finally, Chey and colleagues noted that phase 3 trial results from China have recently provided a proof of principle for an H. pylori vaccine, which “provided about 70% protection against H. pylori acquisition in children.”
Vaccination “remains an attractive long-term solution for managing this infection,” they concluded. – by Adam Leitenberger
Disclosures: Chey reports he is a consultant for Allergan and Takeda. Please see the full guideline for a list of all other authors’ relevant financial disclosures.