MM is a 48 year old female who comes into the ED with complaints of abdominal pain and coffee-ground emesis that has worsened over the last 24 hours. Her past medical history is significant for hypertension and hyperlipidemia. Her home medications include atorvastatin 40 mg daily and lisinopril 10 mg daily with no NSAID use. The ED physician orders an upper endoscopy and a peptic ulcer is found. A subsequent biopsy and urea breath test confirm the presence of Helicobacter pylori. The patient has no prior history of macrolide use or history of drug allergies. The local clarithromycin resistance rate is 19% and the H. pylori eradication rate with clarithromycin in your area is 83%. Which of the following medication regimens is appropriate to start for MM?
A. Clarithromycin BID + metronidazole TID + omeprazole BID
B. Clarithromycin BID + amoxicillin BID + cimetidine BID
C. Bismuth subsalicylate QID + metronidazole TID + tetracycline QID + pantoprazole BID
D. Bismuth subsalicylate QID + metronidazole TID + tetracycline QID + famotidine BID
Answer with rationale:
The correct answer is C.
Peptic ulcer disease has two primary etiologies: NSAID/Aspirin use and Helicobacter pylori or H. pylori. H. pylori is a gram-negative bacterium that can cause chronic inflammation in the stomach or duodenum. Patients who have the presence of H. pylori confirmed by biopsy and a urea breath test or stool antigen test should be started on eradication therapy.
Clarithromycin triple therapy consists of clarithromycin twice daily, amoxicillin twice daily OR metronidazole three times daily (in penicillin allergic patients) and a proton pump inhibitor such as omeprazole twice daily. Clarithromycin triple therapy should only be used in patients who have no prior history of macrolide use, clarithromycin resistance rates < 15% AND H. pylori eradication with clarithromycin rates > 85%, making answers A and B incorrect.
Bismuth quadruple therapy consists of bismuth four times daily, metronidazole three or four times daily, tetracycline four times daily, and a PPI twice daily, making answer C correct.
H. pylori eradication regimens must include a PPI twice daily. PPIs are preferred to H2RAs for higher ulcer healing rates due to stronger acid suppression, making answer D incorrect.
Eradication of H. pylori is dependent on patient adherence. It is important to counsel patients on the importance of taking all of the medications and completing the course to prevent antibiotic resistance. H. pylori eradication treatment duration of therapy is 10-14 days. In patients who receive treatment, eradication should be confirmed 4 or more weeks after completion of therapy.
It is important to note that upon confirmation of H. pylori eradication, PPI maintenance therapy is not typically indicated. Patients who qualify for PPI maintenance therapy must meet one of the following criteria: persistent ulcers on repeat endoscopy, more than 2 peptic ulcers/year, require long term NSAID or aspirin use, H. pylori eradication failure, and patients with ulcers > 2 cm who are > 50 years old with multiple comorbidities.
Have a Happy thanksgiving!