[Helicobacter pylori eradication therapy in Korea]

Zerumbone Inhibits Helicobacter pylori Urease Activity

Helicobacter pylori (H. pylori) produces urease in order to improve its settlement and growth in the human gastric epithelium. Urease inhibitors likely represent potentially powerful therapeutics for treating H. pylori; however, their instability and toxicity have proven problematic in human clinical trials. In this study, we investigate the ability of a natural compound extracted from Zingiber zerumbet Smith, zerumbone, to inhibit the urease activity of H. pylori by formation of urease dimers, trimers, or tetramers. As an oxygen atom possesses stronger electronegativity than the first carbon atom bonded to it, in the zerumbone structure, the neighboring second carbon atom shows a relatively negative charge (δ⁻) and the next carbon atom shows a positive charge (δ⁺), sequentially. Due to this electrical gradient, it is possible that H. pylori urease with its negative charges (such as thiol radicals) might bind to the β-position carbon of zerumbone. Our results show that zerumbone dimerized, trimerized, or tetramerized with both H. pylori urease A and urease B molecules, and that this formation of complex inhibited H. pylori urease activity. Although zerumbone did not affect either gene transcription or the protein expression of urease A and urease B, our study demonstrated that zerumbone could effectively dimerize with both urease molecules and caused significant functional inhibition of urease activity. In short, our findings suggest that zerumbone may be an effective H. pylori urease inhibitor that may be suitable for therapeutic use in humans.

Triple therapy versus sequential therapy for the first-line Helicobacter pylori eradication

Background

The eradication rate of Helicobacter pylori (H. pylori) with triple therapy which was considered as standard first-line treatment has decreased to 70–85%. The aim of this study is to compare 7-day triple therapy versus 10-day sequential therapy as the first line treatment.

Methods

Data of 1240 H. pylori positive patients treated with triple therapy or sequential therapy from January 2013 to December 2015 were analyzed retrospectively. The patients who had undertaken previous H. pylori eradication therapy or gastric surgery were excluded.

Results

There were 872 (74.3%) patients in the triple therapy group, and 302 (25.7%) patients in the sequential therapy group. There was no significant difference between the two groups regarding age, residence, comorbidities or drug compliance, but several differences were noted in endoscopic characteristics and indication for the treatment. The eradication rate of H. pylori by intention to treat analysis was 64.3% in the triple therapy group, and 81.9% in the sequential therapy group (P = 0.001). In per protocol analysis, H. pylori eradication rate in the triple therapy and sequential therapy group was 81.9 and 90.3%, respectively (P = 0.002). There was no significant difference in overall adverse events between the two groups (P = 0.706). For the rescue therapy, bismuth-containing quadruple therapy showed comparable treatment efficacy after sequential therapy, as following triple therapy.

Conclusions

The eradication rate of triple therapy was below the recommended threshold. Sequential therapy could be effective and tolerable candidate for the first-line H. pylori eradication therapy.

[Ten-day Sequential Therapy versus Bismuth Based Quadruple Therapy as Second Line Treatment for Helicobacter pylori Infection]

BACKGROUND/AIMS

Ten-day sequential therapy has been evaluated as the first line therapy for Helicobacter pylori eradication but studies on sequential therapy as a second line therapy is lacking. The aim of this study was to compare the efficacy of 10-day sequential therapy and quadruple therapy as second line treatment for H. pylori eradication after failure of standard triple therapy.

METHODS

Patients who did not respond to standard triple therapy for H. pylori eradication were assigned to either 10-day sequential or bismuth based quadruple therapy as second line treatment from January 2009 to December 2014 at Yeungnam University Medical Center. Post treatment H. pylori status was determined by rapid urease test, giemsa staining, or (13)C-urea breath test. Eradication rate and side effects of both therapies were compared.

RESULTS

A total of 158 H. pylori infected patients were included and 70 patients were treated by bismuth based quadruple therapy and 88 patients by 10-day sequential therapy. Age and sex were not significantly different between the two groups. Eradication rate was 84.3% (59/70) in quadruple group and 56.8% (50/88) in sequential group. Side effects occurred significantly higher in quadruple group than sequential group (27.1% vs. 11.4%, p=0.011).

CONCLUSIONS

For second line H. pylori eradication after failure of standard triple therapy, bismuth based quadruple therapy showed significantly higher H. pylori eradication rate than 10-day sequential therapy. Further prospective studies are needed to evaluate the efficacy of 10-day sequential therapy as a second line H. pylori eradication treatment.

Online Registry for Nationwide Database of Current Trend of Helicobacter pylori Eradication in Korea: Interim Analysis

Eradication of Helicobacter pylori using first-line therapy is becoming less effective. Subjects who had been treated for H. pylori infection were prospectively enrolled through an on-line database registry from October 2010 to December 2012. Demographic data, detection methods, treatment indication, regimens, durations, compliance, adverse events, and eradication results for H. pylori infection were collected. Data of 3,700 patients from 34 hospitals were analyzed. The overall eradication rate of the first-line therapy was 73.0%. Eradication failure was significantly associated with old age, concomitant medication, and comorbidity. Regional differences in eradication rates were observed. The most common first-line therapy was proton pump inhibitor-based triple therapy (standard triple therapy, STT) for 7 days (86.8%). The eradication rates varied with regimens, being 73% in STT, 81.8% in bismuth-based quadruple therapy, 100% in sequential therapy, and 90.3% in concomitant therapy. The eradication rate in treatment-naïve patients was higher than that in patients previously treated for H. pylori infection (73.8% vs. 58.5%, P < 0.001). The overall eradication rate for second-line therapy was 84.3%. There was no statistical difference in eradication rates among various regimens. H. pylori eradication rate using STT is decreasing in Korea and has become sub-optimal, suggesting the need for alternative regimens to improve the efficacy of first-line therapy for H. pylori infection.

An Additive Effect of Oral N-Acetyl Cysteine on Eradication of Helicobacter pylori

Background. Helicobacter pylori is highly adapted to the gastric environment where it lives within or beneath the gastric mucous layer. The aim of this study was to evaluate whether the addition of N-acetyl cysteine to the treatment regimen of H. pylori infection would affect eradication rates of the disease. Methods. A total of 79 H. pylori positive patients were randomized to two therapeutic groups. Both groups received a 14-day course of three-drug regimen including amoxicillin/clarithromycin/omeprazole. Experimental group (38 subjects) received NAC, and control group (41 subjects) received placebo, besides three-drug regimen. H. pylori eradication was evaluated by urea breath test at least 4 weeks after the cessation of therapy. Results. The rate of H. pylori eradication was 72.9% and 60.9% in experimental and control groups, respectively (P = 0.005). By logistic regression modeling, female gender (OR 3.68, 95% CI: 1.06–5.79; P = 0.040) and treatment including NAC (OR 1.88, 95% CI: 0.68–3.15; P = 0.021) were independent factors associated with H. pylori eradication. Conclusion. The results of the present study show that NAC has an additive effect on the eradication rates of H. pylori obtained with three-drug regimen and appears to be a promising means of eradicating H. pylori infection.

Eradication rate and histological changes after Helicobacter pylori eradication treatment in gastric cancer patients following subtotal gastrectomy

AIM: To investigate the eradication rate and histological changes after Helicobacter pylori (H. pylori) eradication treatment following subtotal gastrectomy for gastric cancer.

METHODS: A total of 610 patients with H. pylori infection who had undergone surgery for either early or advanced gastric adenocarcinoma between May 2004 and December 2010 were retrospectively studied. A total of 584 patients with proven H. pylori infection after surgery for gastric cancer were enrolled in this study. Patients received a seven day standard triple regimen as first-line therapy and a 10 d bismuth-containing quadruple regimen as second-line therapy in cases of eradication failure. The patients underwent an esophagogastroduodenoscopy (EGD) between six and 12 mo after surgery, followed by annual EGDs. A further EGD was conducted 12 mo after confirming the result of the eradication and the histological changes. A gastric biopsy specimen for histological examination and Campylobacter-like organism testing was obtained from the lesser and greater curvature of the corpus of the remnant stomach. Histological changes in the gastric mucosa were assessed using the updated Sydney system before eradication therapy and at follow-up after 12 mo.

RESULTS: Eradication rates with the first-line and second-line therapies were 78.4% (458/584) and 90% (36/40), respectively, by intention-to-treat analysis and 85.3% (458/530) and 92.3% (36/39), respectively, by per-protocol analysis. The univariate and multivariate analyses revealed that Billroth II surgery was an independent factor predictive of eradication success in the eradication success group (OR = 1.53, 95%CI: 1.41-1.65, P = 0.021). The atrophy and intestinal metaplasia (IM) scores 12 mo after eradication were significantly lower in the eradication success group than in the eradication failure group (0.25 ± 0.04 vs 0.47 ± 0.12, P = 0.023; 0.27 ± 0.04 vs 0.51 ± 0.12, P = 0.015, respectively). The atrophy and IM scores 12 mo after successful eradication were significantly lower in the Billroth II group than in the Billroth I group (0.13 ± 0.09 vs 0.31 ± 0.12, P = 0.029; 0.32 ± 0.24 vs 0.37 ± 0.13, P = 0.034, respectively).

CONCLUSION: Patients with H. pylori following subtotal gastrectomy had a similar eradication rate to patients with an intact stomach. H. pylori eradication is recommended after subtotal gastrectomy.

[Changes in the eradication rate of conventional triple therapy for Helicobacter pylori infection in Korea]

Although, the prevalence of Helicobacter pylori infection in Korea has declined owing to the eradication therapy, recent seropreva-lence of H. pylori infection is still reported to be as high as 54.4%. Until now, "standard regimen" for eradication of H. pylori has been conventional triple therapy consisting of proton pump inhibitor, amoxicillin, and clarithromycin. However, with the increase in antibiotic resistance, especially against clarithromycin, the eradication rate of conventional triple therapy has steadily declined during the past 13 years in Korea. Present eradication rate of standard triple therapy is reported to be less than 80%, which is the Maginot line of efficacy for the currently available regimen. Therefore, new first line eradication regimen is needed to enhance the eradication rate of H. pylori infection.

Helicobacter pylori recurrence after first- and second-line eradication therapy in Korea: the problem of recrudescence or reinfection

BACKGROUND

Recurrence of Helicobacter pylori (H. pylori) infection is the result of either recrudescence or reinfection. Annual recurrence rates per patient-year of follow-up have been reported to vary across countries. The aim of this study was to analyze recurrence rates of H. pylori after first-line and second-line eradication therapies in Korea.

MATERIALS AND METHODS

From 2007 to 2010, 2691 patients with H. pylori infection received first-line therapy and 573 patients who failed to respond to first-line therapy received second-line therapy. H. pylori infection and the success of eradication were assessed by endoscopic biopsy and rapid urease test or (13) C-urea breath test. All patients were advised to undergo (13) C-urea breath test or esophagogastroduodenoscopy with biopsy or rapid urease test 6 months after eradication, with annual follow-up thereafter.

RESULTS

The eradication rate of the first-line therapy was 79.9% (1283/1605) and that of the second-line therapy was 90.4% (394/436) by per protocol analysis. Annual recurrence rates sharply declined after 2-year follow-up. Annual recurrence rates within and after 2-year follow-up were 9.3 and 2.0% after first-line therapy and those of second-line therapy were 4.5 and 2.9%, respectively.

CONCLUSIONS

Annual recurrence rates of H. pylori showed a sharp decline after 2-year follow-up after eradication in Korean adults, which is not higher than that of Western countries. Enough time interval after treatment (i.e., 2 years) is necessary to confirm eradication, and it would not be easy to distinguish between recurrence and recrudescence before 2 years without identifying H. pylori strains.

Levofloxacin, Metronidazole, and Lansoprazole Triple Therapy Compared to Quadruple Therapy as a Second-Line Treatment of Helicobacter pylori Infection in Korea

Background/Aims

Several rescue therapies have been recommended to eradicate Helicobacter pylori infection in patients with a failure of first-line eradication therapy, but they still fail in more than 20% of cases. The aim of this study was to evaluate the efficacy and safety of levofloxacin, metronidazole, and lansoprazole (LML) triple therapy relative to quadruple therapy as a second-line treatment.

Methods

In total, 113 patients who failed first-line triple therapy for H. pylori infection were randomly assigned to two groups: LML for 7 days and tetracycline, bismuth subcitrate, metronidazole and lansoprazole (quadruple) for 7 days.

Results

According to intention-to-treat analysis, the infection was eradicated in 38 of 56 patients (67.9%) in the LML group and 48 of 57 (84.2%) in the quadruple group (p=0.042). Per-protocol analysis showed successful eradication in 38 of 52 patients (73.1%) from the LML group and 48 of 52 (92.3%) from the quadruple group (p=0.010). There were no significant differences in the adverse effects in either treatment group.

Conclusions

LML therapy is less effective than quadruple therapy as a second-line treatment for H. pylori infection. Therefore, quadruple therapy should be considered as the primary second-line strategy for patients experiencing a failure of first-line H. pylori therapy in Korea.

Efficacy of Proton Pump Inhibitor-based Triple Therapy and Bismuth-based Quadruple Therapy for Helicobacter pylori Eradication in Korean Children

PURPOSE

The aim of this study was to assess and compare the efficacies of proton pump inhibitor-based triple therapy and bismuth-based quadruple therapy as first-line treatments for Helicobacter pylori eradication in Korean children.

METHODS

We retrospectively reviewed the data of children who had been diagnosed with H. pylori infection at the Seoul National University Bundang Hospital from March 2004 to August 2012. The patients were randomly assigned to receive either triple therapy consisting of omeprazole, amoxicillin, and clarithromycin for 2 weeks (OAC group) or quadruple therapy comprising omeprazole, amoxicillin, metronidazole, and bismuth salts for 1 week (OAMB group). The patients were evaluated for eradication of H. pylori infection at 4 weeks after the completion of the treatment.

RESULTS

Of the 129 children enrolled in this study, 118 (91.5%) were included in the final analysis. The eradication rates in OAC and OAMB groups were 67.7% (42/62) and 83.9% (47/56), respectively, which were significantly different between the 2 treatment groups (p=0.041). The eradication rates in the OAMB group during the periods 2004-2006, 2007-2009, and 2010-2012 were superior to those in the OAC group.

CONCLUSION

This study indicated that the 1-week bismuth-based quadruple therapy, compared with the standard 2-week triple therapy, was significantly more successful in eradicating H. pylori infection in Korean children.

Rifaximin Plus Levofloxacin-Based Rescue Regimen for the Eradication of Helicobacter pylori

Background/Aims

This study assessed the efficacy of a rifaximin plus levofloxacin-based rescue regimen in patients that had failed both triple and quadruple standard regimens for the eradication of Helicobacter pylori.

Methods

We treated patients for H. pylori between August 2009 and April 2011. The triple regimen consisted of combined treatment with amoxicillin, clarithromycin, and pantoprazole for 1 week. For failed cases, a quadruple regimen of tetracycline, metronidazole, bismuth dicitrate, and lansoprazole for 1 week was administered. The rescue regimen for persistently refractory cases was rifaximin 200 mg t.i.d., levofloxacin 500 mg q.d., and lansoprazole 15 mg b.i.d. for 1 week.

Results

In total, 482 patients were enrolled in this study. The eradication rates associated with the first and second regimens were 58% and 60%, respectively. Forty-seven out of 58 patients who failed with the second-line regimen received rifaximin plus levofloxacin-based third-line therapy. The eradication rate for the third regimen was 65%. The cumulative eradication rates were 58%, 85%, and 96% for each regimen, respectively.

Conclusions

A rifaximin plus levofloxacin-based regimen could be an alternative rescue therapy in patients with resistance to both triple and quadruple regimens for the eradication of H. pylori.