From the Guidelines
For a patient with H. pylori gastritis who is allergic to tetracycline, I recommend a concomitant non-bismuth quadruple therapy consisting of a proton pump inhibitor (PPI) such as omeprazole 20 mg twice daily, amoxicillin 1000 mg twice daily, metronidazole 500 mg twice daily, and clarithromycin 500 mg twice daily for 14 days, as this regimen is recommended by all recent guidelines 1. This regimen is a suitable alternative to bismuth quadruple therapy, which typically includes tetracycline. The concomitant non-bismuth quadruple therapy has been shown to be effective in eradicating H. pylori infection, with a high cure rate 1.
- The PPI helps reduce gastric acid production, creating a more favorable environment for antibiotics to work.
- Amoxicillin and metronidazole target different aspects of bacterial metabolism to effectively eradicate H. pylori.
- Clarithromycin is a macrolide antibiotic that is effective against H. pylori. It's essential to advise the patient to complete the full course of treatment even if symptoms improve before completion. After completing treatment, confirm eradication with either a urea breath test, stool antigen test, or endoscopic biopsy at least 4 weeks after therapy and after PPI discontinuation for at least 2 weeks 1. If the patient is also allergic to penicillin, substitute amoxicillin with levofloxacin 500 mg once daily, as part of a levofloxacin triple therapy regimen, which includes a PPI and clarithromycin or metronidazole 1. Alternatively, a rifabutin-containing therapy can be considered as a rescue option, consisting of a PPI, amoxicillin, and rifabutin 1.
From the FDA Drug Label
1.2 Eradication of H. pylori to Reduce the Risk of Duodenal Ulcer Recurrence Triple Therapy: Lansoprazole /amoxicillin /clarithromycin Lansoprazole delayed-release capsules in combination with amoxicillin plus clarithromycin as triple therapy is indicated in adults for the treatment of patients with H pylori infection and duodenal ulcer disease (active or one year history of a duodenal ulcer) to eradicate H. pylori. Dual Therapy: Lansoprazole /amoxicillin Lansoprazole delayed-release capsules in combination with amoxicillin as dual therapy is indicated in adults for the treatment of patients with H pylori infection and duodenal ulcer disease (active or one-year history of a duodenal ulcer) who are either allergic or intolerant to clarithromycin or in whom resistance to clarithromycin is known or suspected
The patient with H. pylori gastritis who is allergic to tetracycline can be treated with Dual Therapy: Lansoprazole /amoxicillin as the label does not mention tetracycline as part of the regimen, and the allergy to tetracycline does not affect the use of lansoprazole and amoxicillin 2.
- The Dual Therapy is indicated for patients who are allergic or intolerant to clarithromycin, but it can also be considered for patients allergic to other antibiotics not included in the regimen, such as tetracycline.
- However, it is essential to note that the label does not explicitly address the use of this regimen for patients with H. pylori gastritis who are allergic to tetracycline, but it does indicate its use for patients with H. pylori infection and duodenal ulcer disease.
- Given the information provided, the Dual Therapy: Lansoprazole /amoxicillin can be considered a possible treatment option for the patient.
From the Research
Treatment Regimens for H. pylori Gastritis
For a patient with H. pylori gastritis who is allergic to tetracycline, the following treatment regimens can be considered:
- Clarithromycin triple therapy (clarithromycin, proton pump inhibitor [PPI], and amoxicillin or metronidazole) 3
- Concomitant therapy (clarithromycin, PPI, amoxicillin, and metronidazole) 3
- Proton-pump inhibitor and amoxicillin-based triple therapy containing clarithromycin (PAC) or metronidazole (PAM) 4
- High-dose dual therapy (proton-pump-inhibitor plus amoxicillin) 5
Considerations for Treatment Selection
When selecting a treatment regimen, the following factors should be considered:
- Antibiotic resistance patterns 3, 6, 5
- Patient age and comorbidities 4, 6
- Previous treatment failures 3, 7
- Potential side effects and interactions 7, 5
Alternative Treatment Options
Alternative treatment options, such as levofloxacin-, rifabutin-, furazolidone-, and sitafloxacin-containing regimens, may be considered as salvage options or in cases where first-line treatments are not effective 5. Additionally, the use of probiotics may improve the performance of H. pylori eradication regimens and tolerability 5.