Therapeutic effects of lansoprazole on peptic ulcers in elderly patients

Twice-a-day quadruple therapy for eradication of Helicobacter pylori in the elderly

BACKGROUND

Midday and evening twice-a-day quadruple therapy appears to be the most effective therapy for Helicobacter pylori infection in Northern Sardinia, a site where antibiotics resistance is common.

AIM

The objective of our study was to estimate the efficacy, side-effects, and compliance of a quadruple therapy containing esomeprazole in a group of dyspeptic elderly patients.

PATIENTS AND METHODS

Consecutive elderly patients positive for H. pylori infection and not previously treated for eradication were enrolled. Therapy consisted of esomeprazole 20 mg, tetracycline 500 mg, metronidazole 500 mg, and bismuth subcitrate tablets 240 mg, all twice-a-day with the midday and evening meals, for 10 days. Efficacy was evaluated using 13C-urea breath testing. Compliance was assessed after completing treatment and at follow up. Side effects were graded based on daily activities.

RESULTS

Ninety-five dyspeptic patients (range 65-81 years), 52 men and 43 women, were enrolled. The intention-to-treat cure rate was 91% (81 of 89; 95% CI = 88-99%) and, 95% (81 of 85; 95% CI = 83-96%) per-protocol analysis. Compliance was excellent. Mild-moderate side effects occurred in 27 patients.

CONCLUSIONS

Esomeprazole containing quadruple therapy was highly successful for initial eradication of H. pylori in elderly patients.

High rate of Helicobacter pylori eradication with sequential therapy in elderly patients with peptic ulcer: a prospective controlled study

BACKGROUND

Helicobacter pylori eradication rates with triple therapies are decreasing, and few data in elderly patients are available. A 10-day sequential regimen succeeded in curing such H. pylori infection in unselected patients.

AIM

To compare this sequential regimen and the standard triple therapy for H. pylori eradication in geriatric patients with peptic ulcer.

METHODS

Overall, 179 H. pylori-infected patients with peptic ulcer were enrolled (mean age: 69.5 years; range: 65-83). Patients were randomized to 10-day sequential therapy (rabeprazole 20 mg b.d. plus amoxicillin 1 g b.d. for the first 5 days, followed by rabeprazole 20 mg, clarithromycin 500 mg and tinidazole 500 mg, all b.d., for the remaining 5 days) or standard 7-day triple regimen (rabeprazole 20 mg, clarithromycin 500 mg and amoxicillin 1 g, all b.d.). Helicobacter pylori status was assessed by histology and rapid urease test at baseline and 4-6 weeks after completion of treatment.

RESULTS

The sequential regimen achieved eradication rates significantly higher in comparison with the standard regimen at both intention-to-treat (94% vs. 80%; P = 0.008) and per-protocol (97% vs. 83%; P = 0.006) analyses. In both treatment groups, compliance to the therapy was high (> 95%), and the rate of mild side-effects was similarly low (< 12%). At repeated upper endoscopy, peptic ulcer lesions were healed in 97% patients, without a statistically significant difference between the sequential regimen and the standard triple therapy.

CONCLUSIONS

In elderly patients with peptic ulcer disease, the 10-day sequential treatment regimen achieved significantly higher eradication rates in comparison with standard triple therapy.

Aging and upper gastrointestinal disorders

The prevalence of upper gastrointestinal (GI) diseases is increasing in subjects aged 65 years and over. Pathophysiological changes in esophageal functions that occur with aging may, at least in part, be responsible for the high prevalence of gastro-esophageal reflux disease (GERD) in old age. GERD symptoms are different in the elderly compared to young or adult patients; moreover, esophagitis is a more severe disease in the elderly than in young subjects, relapse occurring in a high percentage of cases in those elderly patients who are not in maintenance therapy with antisecretories. In old age, PPIs are more effective than H2-blockers in healing and reducing the relapse of esophagitis; PPI therapy is well tolerated and very effective even in elderly subjects with concomitant diseases and treatments. Discontinuing maintenance treatment with PPIs after 6 months is associated with a significant increase in the relapse rate. The incidence of gastric and duodenal ulcers and their bleeding complications is increasing in old-aged populations worldwide. Approximately 53-73% of elderly peptic ulcer patients are Helicobacter pylori positive; however, the percentage of H. pylori-positive elderly patients who are treated for their infection remains very low. We now have data that demonstrate the benefit of curing H. pylori infection in elderly patients with H. pylori-associated peptic ulcer disease and severe chronic gastritis. One-week PPI-based triple therapy regimens including clarithromycin, amoxycillin and/or nitroimidazoles are highly effective and well tolerated in elderly patients. Low doses of both PPIs and clarithromycin (in combination with standard doses of amoxycillin or nitroimidazoles) are sufficient. Almost 40% of GU and 25% of DU in the elderly patients are associated with the use of NSAID and/or aspirin. Several strategies are available to prevent NSAID-related peptic ulcers, i.e. the use of low doses and/or less damaging NSAIDs, the use of coxibs, gastroprotection with antisecretory drugs, the eradication of H. pylori infection in infected patients as well as educational programs to reduce inappropriate prescriptions. Strategies for subgroups of patients that will take account of the GI and non-GI risks, i.e. disability, co-morbidity and friality of patients, according to a comprehensive geriatric assessment are recommended.

Review article: an approach to Helicobacter pylori infection in the elderly

The prevalence of Helicobacter pylori infection increases with age world-wide, reaching levels of 40-60% in asymptomatic elderly subjects and over 70% in elderly patients with gastroduodenal diseases. However, the percentage of H. pylori-positive elderly patients who are treated for their infection remains very low. Data are now available that demonstrate the benefit of curing H. pylori infection in elderly patients with H. pylori-associated peptic ulcer disease and severe chronic gastritis. Furthermore, the cure of H. pylori may prevent the progression of intestinal metaplasia and gastric atrophy. New studies are needed to clarify the role of eradication in elderly patients with non-ulcer dyspepsia and gastro-oesophageal reflux disease and in those who use non-steroidal anti-inflammatory drugs. H. pylori infection may be easily diagnosed by histological evaluation, rapid urease test or culture performed on gastric biopsies taken during endoscopy. However, the biopsy site must be carefully selected in elderly patients. For non-invasive monitoring of H. pylori infection after treatment, the 13C-urea breath test has significantly higher accuracy than serology in the elderly; further studies are needed to clarify the role of the H. pylori stool antigen test in old age. One-week proton pump inhibitor-based triple therapy regimens, including clarithromycin, amoxicillin and/or nitroimidazoles, are highly effective and well tolerated in elderly patients. Low doses of both proton pump inhibitors and clarithromycin (in combination with standard doses of amoxicillin or nitroimidazoles) are sufficient. Low compliance and antibiotic resistance are the main factors related to treatment failure in old age.

Helicobacter pylori-associated peptic ulcer disease in older patients: current management strategies

The incidence of peptic ulcer and its severe complications, i.e. bleeding or perforation, is increasing in elderly patients worldwide. The prevalence of Helicobacter pylori infection in patients with peptic ulcer aged over 65 years has been reported to range from 58 to 78%. However, in elderly patients hospitalised for ulcer disease, the rate of diagnostic screening or treatment for H. pylori infection was less than 60%, and only 50 to 73% of patients who had a positive H. pylori test were treated with antibacterials. The eradication of H. pylori infection is known to be of proven benefit for elderly patients with H. pylori-associated ulcer disease. Significant improvement of the clinical outcome, and reduction of ulcer recurrences, symptoms and histological signs of ulcer-associated chronic gastritis activity, as well as decreased costs in elderly healthcare, all result from successful therapy. Proton pump inhibitor (PPI)-based triple therapy regimens including clarithromycin, amoxicillin and/or nitroimidazoles are highly effective and well tolerated in elderly patients, particularly if therapy is of a short duration and low doses of both the PPI and clarithromycin are used. Resistance of H. pylori to antibacterials and low compliance are the major reasons for treatment failure. Surveillance of H. pylori susceptibility to antibacterials at the regional level and enhanced compliance programmes give promising results that suggest new approaches to anti-H. pylori treatment, especially in elderly patients. The role of H. pylori infection in nonsteroidal anti-inflammatory drug (NSAID)-related peptic ulcer still remains controversial. At present, no clear evidence supports the testing and treatment of H. pylori infection for the prevention of drug-related peptic ulcer in elderly patients receiving an NSAID or aspirin (acetylsalicylic acid). After therapy, elderly patients with peptic ulcer may be re-evaluated by invasive methods, i.e. endoscopy and gastric biopsies. or by noninvasive methods. In elderly patients, the 13C-urea breath test demonstrated significantly higher sensitivity, specificity and diagnostic accuracy for detecting H. pylori infection than anti-H. pylori antibodies.

Pooled analysis of Helicobacter pylori eradication regimes in Asia

BACKGROUND AND AIMS

Differences in Helicobacter pylori strains and their resistance to antimicrobials between Asian and Western countries may affect the success in eradicating this bacterium. Our objective was to systematically review the regimens that have been tested in Asia.

METHODS

Data on anti-H. pylori therapies reported from Asia in a large number of publications identified up to December 1998 were pooled into a few groups based on the combination of drugs used. A comparison of different groups was made by calculating the pooled eradication rates.

RESULTS

Seventy-three studies with 134 treatment arms were reviewed. Pooled eradication rates of dual, triple and quadruple therapies were 61.0, 86.5 and 93.4%, respectively. Proton pump inhibitor (PPI)-based combinations were more widely used and effective, with overall eradication rates of 90.7% in triple therapy and 93.4% in quadruple therapy. Bismuth combined with tetracycline and metronidazole also showed a high eradication rate of 92.0%.

CONCLUSIONS

Proton pump inhibitor-based triple therapy with either clarithromycin, amoxycillin or metronidazole was one of the most commonly used and effective anti-H. pylori triple therapy regimens in Asia. The classical triple therapy with a bismuth, tetracycline and metronidazole combination has a similar efficacy. The results of anti-H. pylori treatment in Asia are not different from those in Western countries.

Efficacy of 7 day lansoprazole-based triple therapy for Helicobacter pylori infection in elderly patients

BACKGROUND

The prevalence of Helicobacter pylori increases with age. However, data regarding the effects of anti-H. pylori treatments in the elderly are very scarce.

METHODS

To evaluate the effect of three lansoprazole-based, 7 day, triple-therapy regimens on H. pylori eradication rates, symptomatology, chronic gastritis activity and serological markers of H. pylori infection in elderly subjects, we studied 150 symptomatic patients over 60 years of age with H. pylori-positive duodenal ulcer (DU, n = 34), gastric ulcer (GU, n= 19) or chronic gastritis (CG, n = 97). Patients were consecutively treated with one of the following regimens: (A) lansoprazole (LNS) 30 mg b.i.d. + clarithromycin (CLR) 250 mg b.i.d. + metronidazole (MTR) 250 mg q.i.d.; (B) LNS 30mg b.i.d. + amoxycillin (AMOX) 1 g b.i.d. + MTR 250 mg q.i.d.; and (C) LNS 30 mg b.i.d. + CLR 250 mg b.i.d. + AMOX 1 g b.i.d.

RESULTS

Two months after therapy, the eradication rates of the three treatments, expressed using both intention-to-treat and per-protocol analyses were, respectively; group A, 86 and 91.5%; group B, 80 and 87%; group C, 82 and 89.1%. After therapy, a significant reduction in epigastric pain (P<0.001), heartburn (P=0.02), dyspepsia (P<0.001) and vomiting (P< 0.005) was observed independently of the success of H. pylori eradication. A significantly higher percentage of asymptomatic patients were in the GU-DU group than in CG group (87.7 vs 70.0%, P= 0.032). After therapy, 33 subjects still suffered from symptoms. Persistence of symptoms was significantly associated with an endoscopic diagnosis of oesophagitis and not with H. pylori infection. Patients cured of H. pylori infection showed a significant decrease in the histological activity of both antral and body gastritis (P< 0.0001), a significant drop in immunoglobulin (Ig) G anti-H. pylori antibodies (P< 0.0001) and pepsinogen (PG) C (P<0.0001) and an increase in the PGA/PGC ratio (P<0.0001).

CONCLUSIONS

The 7 day, lansoprazole-based triple therapy was well tolerated and highly effective in the cure of H. pylori infection, the reduction of symptoms, chronic gastritis activity and serum levels of IgG anti-H. pylori antibodies and PGC. Persistence of symptoms after therapy was significantly higher in CG than GU and DU patients and was significantly associated with oesophagitis.

Lansoprazole. An update of its pharmacological properties and clinical efficacy in the management of acid-related disorders

Lansoprazole is a proton pump inhibitor that reduces gastric acid secretion. It has proved effective in combination regimens for the eradication of Helicobacter pylori and as monotherapy to heal and relieve symptoms of gastric or duodenal ulcers and gastro-oesophageal reflux. After initial healing, it may be used to prevent recurrence of oesophageal erosions or peptic ulcers in patients in whom H. pylori is not the major cause of ulceration and to reduce basal acid output in patients with Zollinger-Ellison syndrome. Usual dosages are 15 to 60 mg/day, although dosages of < or = 180 mg/day have been used in patients with hypersecretory states. In patients with duodenal or gastric ulcer, short term lansoprazole monotherapy was similar to omeprazole and superior to histamine H2 receptor antagonists in achieving healing rates > 90%. Lansoprazole was as effective a component of H. pylori eradication regimens as omeprazole, tripotassium dicitrato bismuthate (colloidal bismuth subcitrate) or ranitidine. Lansoprazole was superior to ranitidine in symptom relief and healing of gastro-oesophageal reflux disease and tended to relieve symptoms more rapidly than omeprazole, although initial healing was similar. As maintenance treatment, lansoprazole was similar to omeprazole and superior to ranitidine in relieving symptoms and preventing relapse. Lansoprazole was also superior to ranitidine in healing and relieving symptoms of oesophageal erosions associated with Barrett's oesophagus; healing was maintained for a mean of 2.9 years in > or = 70% of patients. Lansoprazole was also superior to ranitidine in prophylaxis of redilatation of oesophageal strictures. After > or = 4 years of use in patients with Zollinger-Ellison syndrome, lansoprazole 60 to 180 mg/day effectively controlled basal acid output. Dosages may be reduced in some patients once healing and symptom relief has been achieved. Preliminary studies of lansoprazole in patients at risk of aspiration pneumonia or stress ulcers show promise. Although studies show lansoprazole is potentially effective in treating gastrointestinal bleeding, future studies should assess patients' H. pylori status. Lansoprazole has been well tolerated in clinical trials, with headache, diarrhoea, dizziness and nausea appearing to be the most common adverse effects. Tolerability of lansoprazole does not deteriorate with age and the drug is well tolerated in long term use (< or = 4 years) in patients with Zollinger-Ellison syndrome or reflux disease. Thus, lansoprazole is an important alternative to omeprazole and H2 receptor antagonists in acid-related disorders. In addition to its efficacy in healing or maintenance treatment, it may provide more effective symptom relief than other comparator agents.