1. Treatment of H Pylori -Peptic Ulcer Disease By Prof. Hanan Hagar Department of Physiology and Pharmacology

2. H Pylori Helicobacter pylori: Helicobacter pylori: is a spiral-shaped bacterium that accounts for more than 90% of duodenal ulcers and up to 80% of gastric ulcers. causes chronic mucosal inflammation. produces enzymes that causes tissue damage and ulcer.

3. Helicobacter pylori in association with gastric mucosa

4. Helicobacter pylori is the major etiological factor Helicobacter pylori is the major etiological factor in peptic ulcer disease (PUD). in peptic ulcer disease (PUD). All individuals with PUD must be evaluated for All individuals with PUD must be evaluated for H. pylori. H. pylori. Patients with H. pylori should be treated. Patients with H. pylori should be treated. Eradication is important to prevent recurrence of ulcer.

5. How is an H. pylori-induced ulcer treated? A combination of antibiotics and acid-reducing medicines is the most effective treatment.  PPIs or H2 receptor blockers  Antibiotics Clarithromycin Tetracycline or amoxicillin Metronidazole if patient allergic to penicillin.  Bismuth subsalicylate (Pepto-Bismol).

6. Triple therapy Is first-line therapy consisting of: 1. Proton pump inhibitors (PPIs) 2. Clarithromycin 3. Amoxicillin. N.B. Metronidazole is substituted to amoxicillin for patients allergic to penicillin.

7. Quadruple therapy (Bismuth-based regimen) consisting of: 1. Proton pump inhibitors (PPIs) 2. Bismuth subcitrate 3. Metronidazole 4. Tetracycline

8. Treatment should be initiated with a proton pump inhibitor–based three-drug regimen. Treatment should be initiated with a proton pump inhibitor–based three-drug regimen. The selection of an HP eradication regimen should be based on efficacy, safety, antibiotic resistance and cost. The selection of an HP eradication regimen should be based on efficacy, safety, antibiotic resistance and cost. If a second course of HP therapy is required, the regimen should contain different antibiotics. If a second course of HP therapy is required, the regimen should contain different antibiotics.

9. DURATIONDOSEREGIMEN 10 to 14 days 20 mg bid 500 mg bid Omeprazole Metronidazole Clarithromycin 20 mg bid 1g bid 500 mg bid Omeprazole Amoxicillin Clarithromycin 14 days 20 mg bid 525 mg qid 250 mg qid 500 mg qid Omeprazole Bismuth subsalicylate Metronidazole Tetracycline

10. Bismuth subsalicylate Mechanism of Action 1. It enhances mucosal protection by forming a coat over irritated mucosal surfaces that prevent effect of HCl. 2. Promote healing of ulcer. 3. Bactericidal effect against H pylori.

11. USES 1. Eradication of H. pylori. 2. Traveler's diarrhea Adverse Effects 1. Black stool / Teeth discoloration. 2. Encephalopathy (in renal dysfunction). 3. Bismuth is radiopaque and may interfere with radiological examinations.

12. Summary Test for H. pylori prior to beginning therapy. Complete H. pylori eradication is required to prevent relapse. Acid-reducing medications are prescribed in case of PUD without H pylori infections. PUD with H pylori infections can be treated with Triple therapy PPI’s + clarithromycin + amoxicillin Quadraple therapy PPI’s + Bismuth + Metronidazole + tetracycline