4th Line Treatment to Eradicate H. Pylori

[mtobler]

Hi Everyone,

Thus far I have been through 3 failed treatments which in retrospect doesn't really surprise me given the fact that I was prescribed the same antibiotics over and over again. Below I have created a list of previous treatments:

1st Line Treatment:
Lansoprazole 30 mg
Clarithromycin 500 mg
Amoxicillin 500 mg

2nd Line Treatment:
Lansoprazole 30 mg
Clarithromycin 500 mg
Metronidazole 500 mg

3rd Line Treatment:
Omeprazole 20 mg
Clarithromycin 500 mg
Flagyl 500 mg


At this point I have become extremely frustrated because after contracting h. pylori 6 years ago I just cant seem to rid myself of this awful curse !
I would really love to get some insight from medical professionals as well as people who have gone through previous unsuccessful attempts to eradicate h. pylori and hear how they approached this problem with success...

Thank You

[mtobler]

All 3 Treatments were for 14 Days

[Helico_scientist]

Hi, We treat patient like you in our Clinic in Western Australia. We have recently published a paper about our quadruple therapy which has a very high cure rate. Maybe you can see with your GP if he can prescribe one of these treatments.
http://onlinelibrary.wiley.com/doi/10.1 ... 9/abstract

[Helico_expert]

Flagyl is metronidazole. So I see no difference between 2nd and 3rd treatment. Check the treatment plan from the supportive document and discuss with your GP.

supportive document
http://onlinelibrary.wiley.com/store/10 ... 4ca1d1eb37

[mtobler]

Hi & Thanks for both of your swift replies !

My big mistake was to seek treatment through random walk-in clinic Dr's rather than go to a Gastroenterologist in the first place. I am somewhat confident the Quadruple therapy treatment would be successful in my case, however what I am not certain about is what antibiotics to request ? There are obviously custom tailored quadruple treatments depending on the individuals treatment history: Can one of you recommend a good treatment regime based on my previous unsuccessful attempts ?

[mtobler]

From what I gather after reading the supportive document is that if one develops a resistance to clarithromycin then levofloxacin would make an equally effective alternative. And In place of omeprazole or lansoprazole I could either use: Pantoprazole or Rabeprazole. As far as the 2nd antibiotic (metronidazole) I'm not quite sure what I should use because i've used tetracycline in the past for a skin condition and it lost its effectiveness after a while, also it discolored my teeth ! Any ideas ?

[Helico_expert]

In your case, it is best to go see a specialist and book an endoscopy. Ask your specialist to also perform antibiotic susceptibility testing and use the right drug and kill in once and for all.

However, if that is not accessible, you'll probably have to try the PARC or PBRC treatment. Both treatment were shown equally good in our country (low ciprofloxacin and rifabutin resistance). Your specialist should know the resistance profile in your country.

in terms of PPI, they are all the same. Rabeprazole, pentaprazole, omeprazole, esomeprazole, etc. pick any one. but in our study, we use extra high dose of PPI because of ciprofloxacin being not effective in acid condition. so, have to have high dose PPI.

[mtobler]

Hi and Thank you for your informative reply !

Currently I am actually seeing a Gastroenterologist, but he does not consider H. Pylori anything to worry about and has completely dismissed it as problematic. Well, obviously I do not share his opinion. When I contracted H. Pylori 6 years ago it completely put my life upside down, I am suffering all kinds of health problems as a result ! But obviously it would be completely pointless to discuss this with any doctor because they approach medicine in a traditional way rather than being open to additional possibilities.
In regards to the PBRC treatment I was curious whether it matters if I substitute levofloxacin for rifabutin ? The reason I am asking is because I have Neutropenia a condition that causes low WBC, and I read that a possible side effect of rifabutin is temporary neutropenia.

[barjammar]

Final Reply
Neutropenia is somewhat idiosyncratic which means people who have a reaction to the rifabutin would likely develop it. As I review your past treatments my comments are:
1. Repeated treatments with clarithromycin or metronidazole are not very useful.
2. Since the acid blocker is inexpensive and relatively harmless, a much bigger dose is worth the effort and cost.
3. Similarly with amoxicillin, 1G three times daily adds some extra value and Helicobacter pylori never becomes resistant so keep using that part. It has been shown that even when it was used before, amoxicillin still has a good cure rate when given with a strong acid blocker.
4. So far, you have not used ciprofloxacin (as far as I can see). So if you use it, don't waste it by just adding it to a weak treatment. Add it to a strong treatment.
5. In Hong Kong, some years back, a cure rate of 90% was aceived in penicillin allergic people by using rifabutin and levofloxacin plus an acid blocker.
Putting this all together, you can see that our PARC treatment combines several good treatments in one.
As Helico Expert recommended, it is my first choice too.
You must discuss this with your doctor and make a decision yourself. Every patient is unique and our experience does not include people with chronic neutropenia. Depending on the cause of your neutropenia, the concern about rifabutin may be relative. In PARC, you actually only take the ciprofloxacin and rifabutin for five days (d6-d10). If you want a bigger safety factor, at least one person I know uses a lower dose of rifabutin, 150 mg per day only. If you wanted to go with that then I would suggest 150 mg two doses on day 6 then 150 mg one dose per day on days 7-10. Also, check your white cells before (on day 5) and after (on day 11-12) to see if anything happened.
Finally, lets not write off tetracycline as a possible fall-back treatment. It is a component of several good treatments and the teeth yellowing issue relates to long term use and un-erupted teeth I think. But we mainly use it when people are penicillin-allergic.
p.s. If I see anything new about this issue I will add it here below.

I looked at serveral references and have the following comments - which fit with my own experience..
A) Don't give rifabutin with clarithromycin as it increases the blood level of R and increases toxicity.
B) About half of the patients given 300 mg R for 14 days develop a reversible moderate ( 1000/mm^3 cell drop ) in the total white cells. About 1 in 20 patients has a severe drop.
C) Compared with the R doses and duration used in MAC (a type of TB in AIDS patients), the dose and duration is rather low in our PARC treatment (5 days only, and half dose if the regimen I recommended above is used).
D) My own experience from memory, in about four patients, is that the neutropenia, when it occurs, happens in patients who have clinical side effects of the rifabutin
Here is a reference I found in Medline. Your doctor might like to talk to Dr Apseloff who is the expert.
Identifier: 9753212
Authors: Apseloff G. Foulds G. LaBoy-Goral L. Willavize S. Vincent J.
Institution: Department of Pharmacology, The Ohio State University College of Medicine, Columbus 43210-1239, USA.
Title: Comparison of azithromycin and clarithromycin in their interactions with rifabutin in healthy volunteers.
Journal of Clinical Pharmacology. 38(9):830-5, 1998 Sep.
Abstract
A 14-day, randomized, open, phase I clinical trial was designed to examine possible pharmacokinetic interactions between rifabutin and two other antibiotics, azithromycin and clarithromycin, used in the treatment of Mycobacterium avium complex infections. Thirty healthy male and female volunteers were divided into five groups of six participants each: 18 received 300 mg/day of rifabutin, 12 in combination with therapeutic doses of either azithromycin or clarithromycin; the remaining 12 received azithromycin or clarithromycin alone. On day 10 the study was terminated because of adverse events, including severe neutropenia. Fourteen participants who received rifabutin developed neutropenia, including all 12 participants who received azithromycin or clarithromycin concomitantly. Analyses of serum revealed no apparent pharmacokinetic interaction between azithromycin and rifabutin. However, the mean concentrations of rifabutin and 25-O-desacetyl-rifabutin (an active metabolite) in participants who received clarithromycin and rifabutin concomitantly were more than 400% and 3,700%, respectively, of concentrations in those who received rifabutin alone. Physicians should be aware that recommended prophylactic doses of rifabutin may be associated with severe neutropenia within 2 weeks after initiation of therapy, and all patients receiving rifabutin, especially with clarithromycin, should be monitored carefully for neutropenia.

Here is some more information from a similar but earlier Apseloff paper (click to see full size):

High and Low Dose Rifabutin Toxicity in AIDS - with azithromycin

[mtobler]

Greetings Dr. Marschall ,

Firstly, I would like to give you my utmost thanks and appreciation for taking the time to write a lengthy reply in regards to my concerns with Neutropenia. After carefully considering all the treatment options out there I think it's best to go with a treatment regime that has the highest proven success rate. I think in my particular case it would be better to go with the PBRC treatment rather than the PARC because I suffered some allergic complications from taking Amoxicillin the first time. So let me see if I got this right, if I go with the PBRC treatment for those who have a penicillin allergy then I would request the following medications:

20 mg of Rabeprazole three times daily,
240 mg of Bismuth Subcitrate four times daily,
150 mg of Rifabutin twice daily,
and 500 mg of Ciprofloxacin twice daily
All for 10 days ?

Is 10 days sufficient enough ? All my previous treatments were for 14 days ?