The key statements of the Maastricht VI consensus

[The prevalence of mutations underlying development of Helicobacter pylori resistance to antibiotics in Kazan]

BACKGROUND

One of the reasons for the decrease of Helicobacter pylori eradication effectiveness is its resistance to antibiotics.

AIM

To examine the prevalence of H. pylori point mutations responsible for clarithromycin and levofloxacin resistance among the patients with upper gastrointestinal (GI) tract disorders in Kazan.

MATERIALS AND METHODS

The study included 203 patients with symptoms of dyspepsia who underwent upper GI endoscopy at the University Hospital of Kazan Federal University (Kazan, Russia) in 2019-2021. DNA isolation from gastric antrum mucosal biopsies was performed using PureLink Genomic DNA Mini Kits (Thermo Fisher Scientific, USA). Polymerase chain reaction was performed using primers specific for the V-region of the 23S gene and the A subunit DNA gyrase encoding gyrA gene region. The sequencing of obtained DNA fragments was performed on 3730 DNA Analyzer. The sequences were searched for point mutations responsible for H. pylori resistance to clarithromycin (A2143G, A2142G and A2142C193 mutations) and levofloxacin (mutations of the gyrA gene).

RESULTS

H. pylori was detected in 47.78% of biopsy specimens using polymerase chain reaction. The proportion of H. pylori strains with mutations leading to clarithromycin resistance was 17.53%. Amino acid substitutions in the gyrA gene were found in 12.37% of samples. In case of two H. pylori strains (2.06%), dual resistance to clarithromycin and levofloxacin was found.

CONCLUSION

So high incidence of mutations underlying the development of H. pylori resistance to clarithromycin and levofloxacin was observed among examined patients in Kazan.

Classification of chronic gastritis: historical digression and current state of the issue. A review

For more than a century, physicians have noted the relationship of chronic gastritis with the development of gastric cancer, which prompted great interest in the study and systematization of chronic gastritis in order to better understand the prognosis and develop approaches for cancer prevention. The accumulated knowledge about the etiology, pathogenesis and morphology of gastritis has made it possible to coordinate the general ideas about gastritis in the classifications used by practicing physicians today, and the systems developed and implemented into practice for assessing atrophy/intestinal metaplasia (OLGA/OLGIM) undoubtedly can help the doctor in determining the tactics of curation of the patient.

Gastritis and dyspepsia: differentiation as the cornerstone of pharmacotherapy

Chronic gastritis is a complex, polyetiological pathology with no clear clinical presentation. The most significant etiological factor of gastritis to date is H. pylori infection. A common clinical manifestation is the dyspepsia syndrome, which is caused by impaired motility. Symptoms can significantly affect a patient’s quality of life, necessitating rapid and effective pharmacotherapy. This paper discusses the algorithm of the physician actions in the case of a patient with uninvestigated dyspepsia. PPI has significant negative impact on the accuracy of H. pylori diagnostic test results. In this regard, it is proposed to use empirical therapy with prokinetics before diagnostic test would be performed. Among the prokinetics available on the Russian market, itopride hydrochloride stands out due to its high safety profile and proven efficacy. Current evidence supports the use of the prokinetic Ganaton® (itopride hydrochloride) as empirical therapy for dyspepsia of undetermined etiology, including patients with a preliminary diagnosis of gastritis. Due to its dual mechanism of action, itopride hydrochloride alleviates dyspeptic symptoms by improving gastric evacuation and can be used for an extended period. Several studies have shown the superiority of itopride in treating functional dyspepsia compared to other prokinetics, including metoclopramide and domperidone. Thus, prescribing the prokinetic Ganaton® (itopride hydrochloride) as empirical therapy for dyspepsia of undetermined etiology, including patients with a preliminary diagnosis of gastritis, is a pathogenetically justified approach aimed at improving the patient’s condition in the short term before establishing a final clinical diagnosis.

Gastritis and dyspepsia: differentiation as the cornerstone of pharmacotherapy

Chronic gastritis is a complex, polyetiological pathology with no clear clinical presentation. The most significant etiological factor of gastritis to date is H. pylori infection. A common clinical manifestation is the dyspepsia syndrome, which is caused by impaired motility. Symptoms can significantly affect a patient’s quality of life, necessitating rapid and effective pharmacotherapy. This paper discusses the algorithm of the physician actions in the case of a patient with uninvestigated dyspepsia. PPI has significant negative impact on the accuracy of H. pylori diagnostic test results. In this regard, it is proposed to use empirical therapy with prokinetics before diagnostic test would be performed. Among the prokinetics available on the Russian market, itopride hydrochloride stands out due to its high safety profile and proven efficacy. Current evidence supports the use of the prokinetic Ganaton® (itopride hydrochloride) as empirical therapy for dyspepsia of undetermined etiology, including patients with a preliminary diagnosis of gastritis. Due to its dual mechanism of action, itopride hydrochloride alleviates dyspeptic symptoms by improving gastric evacuation and can be used for an extended period. Several studies have shown the superiority of itopride in treating functional dyspepsia compared to other prokinetics, including metoclopramide and domperidone. Thus, prescribing the prokinetic Ganaton® (itopride hydrochloride) as empirical therapy for dyspepsia of undetermined etiology, including patients with a preliminary diagnosis of gastritis, is a pathogenetically justified approach aimed at improving the patient’s condition in the short term before establishing a final clinical diagnosis.

Current trends in <i>Helicobacter pylori</i> eradication therapy

According to the Maastricht VI consensus, the triple therapy (PPI + clarithromycin + amoxicillin) and bismuth-based quadruple therapy (PPI + bismuth + tetracycline + metronidazole) are considered and may be proscribed empirically as first-line regimens in the regions with low clarithromycin resistance rates (<15%). In the regions with high clarithromycin resistance rates (> 15%), as well as in the regions with unknown resistance to this antibacterial agent, it is recommended to use classical quadruple therapy with bismuth drugs as the main choice and quadruple therapy without bismuth drugs (“simultaneous” or “concomitant”) as an alternative. The second-line regimens of empiric choice (when antimicrobial susceptibility testing is not available) include fluoroquinolone-based quadruple therapy (PPI + levofloxacin + amoxicillin + bismuth) or fluoroquinolone-based triple therapy (PPI + levofloxacin + amoxicillin) and bismuth-based quadruple therapy. The Maastricht VI consensus regulates the use of rifabutin-based triple therapy (PPI + amoxicillin + rifabutin) as a “rescue” therapy, if the above ET schemes are ineffective and there is no possibility to conduct an antimicrobial susceptibility test. In its latest clinical guidelines, the Russian Gastroenterological Association (RGA) recommends with a view to achieving maximum treatment efficiency during classic triple ET and levelling the risk of further progression of clarithromycin resistance in Russia to take additional measures to increase its effectiveness (detailed instruction of a patient and control over strict adherence to the prescribed regimen, prolonging the course up to 14 days; prescribing PPI at increased dose twice a day; the latest generation PPIs (rabeprazole and esomeprazole); adding bismuth tripotassium dicitrate (240 mg 2 times a day) to the standard triple therapy; adding cytoprotector rebamipide (100 mg 3 times a day) to the standard triple therapy; adding a probiotic with proven efficacy to the standard triple therapy within controlled studies).