What is the suggested Helicobacter pylori treatment for a patient allergic to Ketorolac (Toradol) and Azithromycin?

From the Guidelines

For a patient allergic to Ketorolac (Toradol) and Azithromycin who needs H. pylori treatment, I recommend a bismuth quadruple therapy regimen consisting of a proton pump inhibitor (such as omeprazole 20mg twice daily), bismuth subsalicylate (525mg four times daily), metronidazole (500mg three times daily), and tetracycline (500mg four times daily) for 14 days, as suggested by the 2019 Gastroenterology study 1. This regimen is preferred because it avoids macrolides like azithromycin and doesn't include NSAIDs like toradol, which the patient is allergic to.

• The bismuth quadruple therapy is a first-line treatment recommended by all guidelines, including the Toronto Consensus, Maastricht V/Florence, and American College of Gastroenterology recommendations, as seen in the study 1.
• The regimen's effectiveness can be attributed to the direct antimicrobial effects of bismuth compounds against H. pylori, while the antibiotics disrupt bacterial cell wall synthesis and protein production.
• The proton pump inhibitor reduces stomach acid, creating a more favorable environment for the antibiotics to work and protecting the gastric mucosa.
• It's essential to advise patients to complete the full course of treatment, even if symptoms improve earlier, as incomplete treatment may lead to antibiotic resistance and treatment failure, as implied by the study's discussion on the importance of completing the recommended treatment duration 1. Alternative regimens, such as a PPI-based triple therapy with amoxicillin and metronidazole, may not be suitable for patients with penicillin allergies, but could be considered in other cases, as mentioned in the study 1.

From the FDA Drug Label

Adult Patients only Helicobacter pylori Infection and Duodenal Ulcer Disease: Triple therapy for Helicobacter pylori (H. pylori) with clarithromycin and lansoprazole : Amoxicillin, in combination with clarithromycin plus lansoprazole as triple therapy, is indicated for the treatment of patients with H pylori infection and duodenal ulcer disease (active or 1-year history of a duodenal ulcer) to eradicate H. pylori. Dual therapy for H. pylori with lansoprazole : Amoxicillin, in combination with lansoprazole delayed-release capsules as dual therapy, is indicated for the treatment of patients with H pylori infection and duodenal ulcer disease (active or 1-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 suggested Helicobacter pylori treatment for a patient allergic to Ketorolac (Toradol) and Azithromycin is amoxicillin in combination with lansoprazole as dual therapy, as the patient is allergic to a macrolide (Azithromycin) which is an alternative to clarithromycin in triple therapy 2.

• Key points:
  • Amoxicillin and lansoprazole can be used for H. pylori treatment in patients allergic to clarithromycin.
  • This dual therapy is indicated for the treatment of patients with H. pylori infection and duodenal ulcer disease.

From the Research

Helicobacter pylori Treatment Options

For a patient allergic to Ketorolac (Toradol) and Azithromycin, the suggested Helicobacter pylori treatment can be considered based on the following options:

• A combination of metronidazole, omeprazole, and clarithromycin, as studied in 3, which showed an 88% cure rate for H. pylori infection.
• A quadruple therapy with a proton pump inhibitor (PPI), bismuth, tetracycline, and metronidazole, as recommended in 4, which achieved a 91% efficacy rate in first-line treatment.

Alternative Treatment Regimens

Other treatment regimens that can be considered include:

• A triple combination with PPI, clarithromycin, and metronidazole, although this regimen had a lower efficacy rate of 69% in 4.
• A levofloxacin-based rescue regimen with a proton-pump inhibitor and clarithromycin, as mentioned in 5, which may be an alternative option, especially when two or more consecutive eradication treatments have previously failed.

Considerations for Patients Allergic to Penicillin

For patients allergic to penicillin, a quadruple regimen with PPI, bismuth, tetracycline, and metronidazole seems to be a better first-line option, as suggested in 4. In cases where this regimen is not suitable, a triple regimen with PPI, clarithromycin, and metronidazole, or a levofloxacin-based rescue regimen, may be considered, as discussed in 5.