Patient on antibiotic regimen for Helicobacter pylori (H. pylori) experiencing heartburn?

From the Guidelines

For a patient experiencing heartburn while on an H. pylori antibiotic regimen, I recommend adding a proton pump inhibitor (PPI) such as omeprazole 20mg twice daily if not already included in their treatment, as suggested by the most recent guidelines 1. Most H. pylori regimens should already contain a PPI, but increasing the dose may help. The patient can also take an antacid like calcium carbonate (Tums) for immediate relief as needed. Heartburn during H. pylori treatment is common due to the irritating effects of antibiotics on the stomach lining. It's essential to complete the full antibiotic course despite discomfort to ensure eradication of the infection. Taking medications with food (except for certain antibiotics like tetracycline that require empty stomach administration) may help reduce irritation. The patient should avoid spicy foods, alcohol, caffeine, and acidic beverages during treatment. If heartburn becomes severe or is accompanied by severe abdominal pain, vomiting, or difficulty swallowing, the patient should contact their healthcare provider as medication adjustments may be necessary, as per the American Gastroenterological Association's guidelines on managing gastroesophageal reflux disease 1. Additionally, the principles of antimicrobial stewardship should be considered when developing guidelines for H. pylori therapy, focusing on optimized, susceptibility-guided therapy to achieve high cure rates 1. Optimizing current therapies, such as adjusting drug administration in relation to meals, may also be beneficial in achieving high cure rates, as seen in studies on bismuth-containing regimens 1. Overall, the goal is to provide effective treatment while minimizing antibiotic resistance and promoting sustainable access to effective therapy.

From the FDA Drug Label

If there is recurrence of EE or GERD symptoms (e.g., heartburn), additional 4 to 8 week courses of omeprazole may be considered. The patient is experiencing heartburn while on an antibiotic regimen for H pylori.

• The recommended treatment for H pylori eradication is a triple therapy regimen, which includes omeprazole, amoxicillin, and clarithromycin, for 10 days 2.
• If the patient experiences recurrence of symptoms, such as heartburn, an additional 4 to 8 week course of omeprazole may be considered 2.
• Lansoprazole is also indicated for the treatment of symptomatic GERD, and can be used for short-term treatment (up to eight weeks) for the treatment of heartburn and other symptoms associated with GERD 3.

From the Research

Patient on Antibiotic Regimen for H pylori Reporting Heartburn

• The patient is experiencing heartburn while on an antibiotic regimen for H pylori, which may be related to the treatment itself or the underlying infection 4.
• Proton pump inhibitors such as omeprazole and lansoprazole are active in vitro against H pylori and are often used in combination with antibiotics to eradicate the infection 4, 5.
• However, the use of antibiotics can also lead to changes in the gut microbiome, which may contribute to heartburn and other gastrointestinal symptoms 6, 7.
• The current treatment strategies for H pylori infection include triple therapy with a proton pump inhibitor and two antibiotics, as well as quadruple therapy with a proton pump inhibitor, bismuth, and two antibiotics 6, 7, 8.
• The choice of treatment regimen depends on various factors, including the patient's medical history, the presence of antibiotic resistance, and the local resistance pattern 6, 7, 8.

Treatment Options for H pylori Infection

• Triple therapy with a proton pump inhibitor and two antibiotics, such as clarithromycin and amoxicillin, is a common treatment regimen for H pylori infection 4, 5.
• Quadruple therapy with a proton pump inhibitor, bismuth, and two antibiotics, such as metronidazole and tetracycline, is also effective in eradicating H pylori infection 6, 7, 8.
• Concomitant and sequential therapy regimens, which involve the use of multiple antibiotics and a proton pump inhibitor, have also been shown to be effective in treating H pylori infection 6, 7.
• The use of probiotics and other adjunctive therapies may also be beneficial in reducing gastrointestinal symptoms and improving treatment outcomes 7.