Since Professor Marshall discovered Helicobacter pylori and won the Nobel Prize in Medicine, this bacterium that has coexisted with human beings for hundreds of thousands of years has gradually become popular from obscurity in the past. The well-known “net red fungus”. It is not only related to chronic gastritis and peptic ulcer, but also closely related to gastric cancer. More and more people take it seriously and receive eradication treatment.
Currently, the standard quadruple therapy recommended by my country’s guidelines, the success rate of eradication is decreasing year by year. treatment, nearly 1/5 of the people will fail to sterilize, and even refractory Helicobacter pylori infection cases are common in clinical practice, So how should we treat ?
What is a refractory H. pylori infection?
The definition of refractory Helicobacter pylori infection (RHPI) is mainly based on the definition of Professor Hu Fulian in China [1], while there is currently no unified definition abroad.
Three or more failures of “standard quadruple therapy” in the “Consensus” within two years;
10-14 days per session;
A full course of treatment is completed according to the “consensus” requirements for each treatment;
Gastroscopic examination was performed before treatment, which was in line with the treatment indications.
Finding reasons for eradication failures is fundamental
Factors affecting the efficacy of H. pylori eradication regimens
1. The choice of antibiotics. The drug resistance of Helicobacter pylori is the main reason leading to the lower and lower eradication rate. Therefore, the selection and course of antibiotics should be based on the local drug resistance of Helicobacter pylori, which varies from person to person.
2. Choice of acid-suppressing drugs. Increasing gastric pH can increase the concentration of anti-Hp IgA in the stomach, the IgA concentration increases, the immune activity in vivo is enhanced, and the Hp eradication rate increases. Multinational guidelines have also pointed out that adequate acid suppression is essential for the eradication of H. pylori. In addition, for the population with the CPY2C19 fast metabolism gene, an appropriate acid suppressant should be selected. Patient compliance is critical. Patients often stop taking the medicine on their own due to various side effects (nausea, vomiting, etc.), or forget to take the medicine because of the fast pace of life. In this regard, doctors should strengthen publicity and education for patients, so that patients can increase their attention to Hp treatment.
3.Smoking reduces eradication rates. Smoking reduces gastric blood flow and mucus secretion, reduces the concentration of antibiotics in the stomach, stimulates gastric acid secretion, and accelerates the metabolism of PPI by cytochrome oxidase P450, resulting in a decrease in gastric pH and an increase in Hp resistance. Strictly quit smoking.
Choosing an individualized treatment plan is the key
We can make breakthroughs in several aspects such as antibiotic selection, use of acid suppressants and individualized H. pylori eradication programs, and design the optimal, Individualized treatment plan.
The quadruple regimen (PPI + bismuth + 2 antibiotics) is currently recommended as the main empirical treatment for Hp eradication.
(1)Antibiotic choice: When choosing antibiotics, doctors should choose Antibiotics with high sensitivity can avoid the transformation of H. pylori eradication failure to refractory H. pylori infection. At the same time, the economic factors and individual characteristics of patients should be considered, and the benefit and risk ratio should be weighed to seek the most suitable drug. Adjust the treatment plan according to the past medication history: If the patient develops drug resistance, the patient’s medication record can be obtained through the electronic medical record system, patient recall, asking relatives/friends/other relevant doctors, etc. Used antibiotics to improve treatment rates.
(2)acid-suppressant options: Pathways relying on smaller PPIs, such as rabeprazole, esomeprazole, vornoprazole, etc., can reduce or avoid the influence of CYP2C19 gene polymorphism Hp eradication rate.
(3)Salvage regimen: When two regimens When both fail, it is likely that patient compliance is not satisfactory, or H. pylori is resistant to one or more antibiotics, and drug susceptibility testing is recommended.
(4)non-Antibiotic therapy[2]: Inhibit or eradicate Helicobacter pylori by affecting inflammatory factors, enhancing mucosal barrier, changing gastric microenvironment, and affecting the adhesion and colonization of Helicobacter pylori in the stomach . Clinical studies have confirmed that adjuvant therapy with traditional Chinese medicine, probiotics, and mucosal protective agents can improve the eradication rate of Helicobacter pylori.
Director Gao Yu, Department of Gastroenterology, Shandong Maternal and Child Health Hospital, reminds everyone again that during the first eradication treatment of Helicobacter pylori, one should not blindly take medicines. Eradication success rate. If it is the second eradication, it should not be carried out immediately and should be carried out at an interval of 3-6 months to restore the sensitivity of the bacteria to antibiotics. The drug selection for re-treatment is more difficult and must be carried out under the guidance of a gastroenterologist. (Text/Edited by Sun Yangxin/Xu Xiao)
Reference source: [1] Hu Fulian, Principles and strategies for treatment of refractory Helicobacter pylori infection [J]. Chinese Journal of Medicine, 2017, 97(10): 721-723.
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[2] Consensus expert group, national consensus on the treatment of Helicobacter pylori-related “disease-syndrome” by integrated traditional Chinese and western medicine [J]. Chinese Journal of Medicine, 2018, 98 (26): 2066-2072 .