Duration of PPI in H Pylori Eradication

• Proton pump inhibitors have both direct and indirect effects on H. pylori eradication.
• The PPIs directly affect H. pylori by reducing its density and causing lysis of the H. pylori at neutral pH in the presence of urea.
• Indirectly, PPIs increase antibiotic concentration in gastric juice by reducing the volume of gastric-acid secretion.
• They increase the permeability of gastric juice by decreasing its viscosity, and they reduce the degradation of acid-labile antibiotics in the stomach by increasing intragastric pH

Shorter Duration

• Laine's study compared 7, 10, and 14 days of omeprazole, amoxicillin, clarithromycin (OAC) therapy and evaluated compliance and side effects. Compliance was perfect at 7 days but worsened at 10 and 14 days of therapy.
• Similarly, side effects did not occur at 7 days but were present both at 10 and 14 days of therapy
• Short-term H. pylori eradication therapy tends to improve compliance, reduce the incidence of side effects, and decrease the cost of therapy by up to 50%

Long Term Use : Against

• Recurrence of ulcers following  H. pylori eradication are uncommon. One prospective study which followed 141 duodenal ulcer and 45 gastric ulcer patients for 9.8 years found no ulcer recurrence after  H. pylori eradication in patients not taking ASA or NSAIDs. Thus, most patients do not require further acid suppression treatment following  H. pylori eradication. Addittional short term acid suppression with PPI or H2RA may be indicated in symptomatic patients.¹
• A 5-yr prospective, randomized, controlled study by Liu et al. in 82 Taiwanese patients with a history of ulcer bleeding demonstrated that maintenance acid suppression was not routinely necessary to prevent ulcer recurrence after successful H. pylori eradication and ulcer healing.²
• Rebound acid hypersecretion occurs in H. pylori-negative subjects after omeprazole treatment. Its severity is related to the degree of elevation of pH on treatment. Persisting suppression of acid secretion masks the phenomenon in H. pylori-positive subjects.³
•  Development of gastric erosions after H. pylori eradication may be controlled by acid suppression treatment. Less severe atrophy or more severe gastritis in oxyntic glands before eradication may be involved in the development of gastric erosions. These results support the idea that recovery of acid secretion may be one of factors for development of gastric mucosal erosions after successful eradication.⁴
• There is one study shows that one-week triple therapy alone is highly effective healing non-complicated H.Pylori associated duodenal ulcer without additional antisecretory treatment.⁵
• The use of proton pump inhibitors for a long periodand presence of H. pylori infection are risk factors for enterochromaffin-like cell hyperplasia
• For uncomplicated duodenal ulcers, once H. pylori has been eradicated, continued PPI use does not produce higher ulcer healing rates and is generally not indicated.

Long Term Use: Supporting

• PPI may be indicated for acute healing of gastric ulcer.

Recommendations

• Prolonged PPI therapy (e.g., for 4 to 8 weeks) after a course of eradication therapy is not routinely recommended for uncomplicated duodenal ulcers but has been recommended for gastric ulcers or complicated duodenal ulcers

References:

1. http://www.rxfiles.ca/rxfiles/uploads/documents/hpylori.pdf
2. http://gi.org/guideline/management-of-helicobacter-pylori-infection/
3. http://www.ncbi.nlm.nih.gov/pubmed/9922302/
4. http://www.ncbi.nlm.nih.gov/pubmed/11966544
5. http://www.ncbi.nlm.nih.gov/pubmed/10962387
6. http://www.aafp.org/afp/2002/0715/p273.html
7. Effects of Helicobacter pylori infection and long-term proton pump inhibitor use on enterochromaffin-like cells. Annals of Gastroenterology (2012) 25, 123-127
8. Test and Treat for Helicobacter pylori in Dyspepsia, British Infection Association
9.  MEDICAID DRUG USE REVIEW CRITERIA FOR OUTPATIENT USE, Drug Information Service, The University of Texas Health Science Center at San Antonio, and the College of Pharmacy, The University of Texas at Austin.
10. PPI DEPRESCRIBING Approaches for stopping or dose reduction of PPIs
    in those who may not need lifelong treatment, April 2015