View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by eCommons@AKU eCommons@AKU Department of Medicine Department of Medicine September 2009 Furazolidone, Co-amoxiclav, Colloidal Bismuth Subcitrate, and Esomeprazole for patients who failed to eradicate Helicobacter pylori with triple therapy Z Abbas Aga Khan University, [email protected] Javed Yakoob Aga Khan University, [email protected] Shahab Abid Aga Khan University, [email protected] Wasim Jafri Aga Khan University, [email protected] Muhammad Islam Aga Khan University See next page for additional authors Follow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_med_med Part of the Gastroenterology Commons Recommended Citation Abbas, Z., Yakoob, J., Abid, S., Jafri, W., Islam, M., Azam, Z., Hilal, I. (2009). Furazolidone, Co-amoxiclav, Colloidal Bismuth Subcitrate, and Esomeprazole for patients who failed to eradicate Helicobacter pylori with triple therapy. Digestive Diseases and Sciences, 54(9), 1953-1957. Available at: https://ecommons.aku.edu/pakistan_fhs_mc_med_med/154 Authors Z Abbas, Javed Yakoob, Shahab Abid, Wasim Jafri, Muhammad Islam, Zahid Azam, and Imran Hilal This article is available at eCommons@AKU: https://ecommons.aku.edu/pakistan_fhs_mc_med_med/154 Dig Dis Sci (2009) 54:1953–1957 DOI 10.1007/s10620-008-0582-6 ORIGINAL ARTICLE Furazolidone, Co-amoxiclav, Colloidal Bismuth Subcitrate, and Esomeprazole for Patients Who Failed to Eradicate Helicobacter pylori with Triple Therapy Zaigham Abbas Æ Javed Yakoob Æ Shahab Abid Æ Wasim Jafri Æ Muhammad Islam Æ Zahid Azam Æ Imran Hilal Received: 22 July 2008 / Accepted: 13 October 2008 / Published online: 5 December 2008 Ó Springer Science+Business Media, LLC 2008 Abstract There is increasing evidence of Helicobacter Introduction pylori (H. pylori) resistance to the classical triple therapy consisting of a proton-pump inhibitor and clarithromycin Triple therapy, a combination of proton-pump inhibitor with either amoxicillin or metronidazole. This study is (PPI) with two antibiotics, remains the recommended first aimed at establishing the efficacy and safety of a 14-day choice anti-Helicobacter pylori (H. pylori) treatment. The regimen to eradicate H. pylori in patients who have failed usual antibiotics used are clarithromycin and amoxicillin with the classical triple therapy given for 14 days. One or metronidazole [1]. However, there is an increasing hundred seventy-six patients diagnosed to have H. pylori evidence of H. pylori resistance to classical triple therapy infection were given triple therapy for 14 days. Fifty-two [2–5]. Increasing resistance to clarithromycin and metro- patients who failed to respond as evident from positive nidazole is being documented as leading to failure of 14C-urea breath test (UBT) done 4–6 weeks after the standard eradication regimes [3, 4]. Amoxicillin-resistant completion of triple therapy were offered a combination H. pylori have also been reported [5]. Another reason for regimen comprised of furazolidone 200 mg b.i.d, co-am- failure is low patient compliance with this treatment due to oxiclav 1 g b.i.d., colloidal bismuth subcitrate 240 mg side effects [6]. Clarithromycin, metronidazole, and b.i.d., and esomeprazole 40 mg b.i.d. for 14 days. The amoxicillin used in therapy may cause several side effects mean age of these patients was 41 ± 13 years (range 20– such as nausea, vomiting, metallic taste in the mouth, 67). Thirty-four were males. To document eradication of H. diarrhea, headache, dizziness, and yeast infections in pylori, UBT was repeated 4 weeks after the completion of women. A regimen useful in one geographical area may treatment. On an intention-to-treat analysis, the eradication not be effective or practical in another area. Bismuth- rate was 81% (42 out of 52) whereas on per-protocol basis, containing quadruple therapy with a PPI, bismuth subci- the eradication rate was 82.4% (42 out of 51). In conclu- trate, metronidazole, and tetracycline given for 2 weeks sion, this new regimen represents a suitable second-line may be a first choice treatment option in an era of increased therapy. clarithromycin resistance [1, 2]. The best first-line and re- treatment regimens have yet to be established. Keywords Helicobacter pylori Á Clarithromycin Á It has been reported that the amoxicillin-clavulanate Furazolidone Á Co-amoxiclav Á Bismuth Á Esomeprazole combination has a higher activity than amoxicillin alone against H. pylori [5, 7]. Furazolidone has also been used in the first-line and rescue regimens [8, 9]. It is an antimicrobial This study was conducted under ClinicalTrials.gov number agent that is both available and inexpensive in developing NCT00520949. countries. It has been used in China for more than 20 years in the treatment of peptic ulcer as the single therapeutic agent, Z. Abbas (&) Á J. Yakoob Á S. Abid Á W. Jafri Á M. Islam Á with healing rates comparable to those obtained with Z. Azam Á I. Hilal cimetidine and displaying lower recidivating rates [10]. The Department of Medicine, The Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan combination therapy with furazolidone, amoxicillin-cla- e-mail: [email protected] vulanate (co-amoxiclav), bismuth compound, and a PPI may 123 1954 Dig Dis Sci (2009) 54:1953–1957 represent an effective therapeutic scheme for the treatment H. pylori Infection of resistant H. pylori infection. It is expected to be better tolerated than clarithromycin-based regimens and effective in the re-treatment for H. pylori infection. This study was Triple Therapy aimed at establishing the efficacy and safety of a 14-day n=176 regimen using the above drugs to eradicate H. pylori in patients who have failed with the classical triple therapy UBT n=171 given for 14 days. H. pylori persist H.pylori n= 52 eradicated n=119 Materials and Methods H. pylori eradicated Patients Quadruple UBT n=51 n=42 Therapy In this prospective, open study, performed between Octo- n=52 ber 2006 and May 2008, we enrolled 176 patients from our H. pylori persist gastroenterology clinic who were diagnosed with H. pylori n=9 infection and had associated endoscopic gastritis, peptic ulcer, or gastroesophageal reflux disease. Informed written Fig. 1 Summary of the study consent was obtained from each patient before entering the trial. Exclusion criteria were evidence of any malignancy, b.i.d., and PPI esomeprazole (Nexum, Getz Pharma) 40 mg gastric outlet syndrome, history of gastric surgery, chronic b.i.d. for 14 days. All patients were evaluated at the end of liver disease, severe chronic renal failure, or any major co- treatment for compliance with drugs and related adverse morbidity, and known or suspected hypersensitivity to the effects during the treatment. To improve the compliance all medication used in the study. Complete history was taken patients were warned of possible side effects beforehand. including present and past history of illness, medications, Therapeutic success was again evaluated by UBT 4 weeks smoking, and alcohol intake. Physical examination was after the completion of treatment (Fig. 1). The study was also performed. Hematological and biochemical tests approved by the ethics committee of the hospital. including complete blood count, blood urea nitrogen, serum creatinine, and liver function tests were carried out. Statistical Analysis Diagnosis of H. pylori infection was made on the basis of any two out of three positive tests, i.e., 14C-urea breath test Statistical calculations were performed with the SPSS (UBT), rapid urease test, or histology on gastric biopsies statistics software, version 10.0 (SPSS Inc., Chicago, obtained at endoscopy, two each from both antrum and USA). Results were presented as mean ± standard devia- body. UBT was done with the Heliprobe System (Noster tion for quantitative variables and numbers and percentages AB, Sweden) and read as described by the manufacturer: for qualitative variables. All patients were evaluated in an 0—patient not infected, I—borderline result, II—patient intention-to-treat (ITT) analysis, in which patients without infected [11]. For the rapid urease test, Pronto Dry (Med- final H. pylori determination or with protocol violations ical Instrument Corp., France) was used with two biopsies, were considered treatment failures. The per-protocol (PP) one each from the antrum and corpus and read at 30 min analysis included all subjects who took at least 80% of each [12]. Hematoxylin and eosin stain was used for the detec- study medication as prescribed and completed the final H. tion of H. pylori. In doubtful cases Giemsa staining was pylori status assessment. carried out to ascertain presence of H. pylori. These patients were given a classical triple regimen of amoxicillin Sample Size 1 g, clarithromycin 500 mg, and omeprazole 20 mg twice a day for 14 days. Eradication of H. pylori was docu- Assuming 90% effectiveness for eradication of H. pylori mented by repeat UBT performed 4 weeks after infection in the study population with 95% confidence level completion of therapy. Patients who failed to eradicate H. and a bound on error of ±8.5%, the estimated sample size pylori were recruited for a new combination protocol was 48 subjects for quadruple therapy; however, for stan- (n = 52). This furazolidone and bismuth-based regimen dard triple therapy the response rate for eradication of H. was comprised of co-amoxiclav (Augmentin, GSK) 1 g pylori infection was expected to be 75%, thus we took b.i.d., furazolidone (Furoxone, GSK) 200 mg b.i.d., col- three times that amount for quadruple therapy, i.e., 144 loidal bismuth subcitrate (Cebes-S, Adamjee) 240 mg subjects. 123 Dig Dis Sci (2009) 54:1953–1957 1955 Results Table 2 Side effects of the second-line therapy (n = 52) Side effect Number of patients (%) One hundred seventy-six patients were enrolled for triple therapy over a period of 20 months. In ITT analysis, Nausea 26 (50%) eradication was achieved in 119 (68%) patients.