Download Helicobacter pylori Infection

A Clinical Reprint
N Engl J Med. 2010; 362: 1597-1604.
Helicobacter pylori Infection
Kenneth E. L. McColl, M.D.
Medical Device Division of
Otsuka America Pharmaceutical, Inc.
Helicobacter pylori Infection
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A 29-year-old man with intermittent epigastric discomfort [< 55 years old with dyspepsia]
There is no weight loss or evidence of GI bleeding [No alarm features]
He reports no use of aspirin or NSAIDs
A serologic test for H. pylori is positive [Passive test vs. active test]
The patient returns with the same symptoms after one H. pylori course of standard triple therapy
[Eradication rate and confirmation of eradication]
This review article highlights...
• the need for proper testing for H. pylori infection,
• current eradication therapy options and limitations, and
• the need for confirming eradication using the right test at the right time
Clinical Problem
Infection with H. pylori is a cofactor in the development of three important upper gastrointestinal diseases:
• Duodenal or gastric ulcers (reported to develop in 1 to 10% of infected patients)
• Gastric cancer (in 0.1 to 3%)
• Gastric mucosa-associated lymphoid-tissue (MALT) lymphoma (in < 0.01%)
“H. pylori infection is classified as a human carcinogen by the World Health Organization.”
Testing for H. pylori Infection
Testing should be done on patients with:
• Confirmed gastric or duodenal ulcers
• Gastric MALT lymphoma
• Resection of early gastric cancers
• Uninvestigated, uncomplicated dyspepsia
Non-invasive testing can be performed with the use of:
• Urea breath test
• Fecal antigen test
• Serologic test (the least accurate)
The 13C urea breath test and the fecal antigen test have a sensitivity and specificity of 95%
Commercially available quantitative serologic assays showed an overall sensitivity and specificity of only 85% and 79%, respectively
H. pylori Eradication
Eradication therapy is prescribed for patients with positive test results.
Eradication:
• Provides a long-term cure of duodenal ulcers in those not associated with the use of NSAIDs
• Reduces the progression of atrophic gastritis
• Causes regression of most localized gastric MALT lymphoma
Various drug regimens are used to treat H. pylori infection, but the eradication rate of the standard triple therapy is only about 77%.
It is important to confirm the eradication of H. pylori infection by means of:
• Urea breath test
• Fecal antigen test
• Endoscopy
These tests should be performed 4 weeks or longer after completion of therapy to avoid false negative results.
Available Tests for Helicobacter pylori Infection*
Non-endoscopic
Serologic test
Widely available; the least expensive of
available tests
Positive result may reflect previous rather than current infection; not
recommended for confirming eradication
Urea breath test
(Active test)
High negative and positive predictive
values; useful before and after treatment
False negative results possible in the presence of PPIs or with recent
use of antibiotics or bismuth preparations; considerable resources
and personnel required to perform test
Fecal antigen test
(Active test)
High negative and positive predictive
values with monoclonal-antibody test;
useful before and after treatment
Process of stool collection may be distasteful to patient; false
negative results possible in the presence of PPIs or with recent use
of antibiotics or bismuth preparations
Urease-based tests
(Active test)
Rapid, inexpensive, and accurate in
selected patients
False negative results possible in the presence of PPIs or with recent
use of antibiotics or bismuth preparations
Histologic assessment
Good sensitivity and specificity
Requires trained personnel
Culture
Excellent specificity; provides opportunity
to test for antibiotic sensitivity
Variable sensitivity; requires trained staff and properly equipped
facilities
Endoscopic
* PPI denotes proton-pump inhibitor.
Conclusions and Recommendations
Non-invasive test-and-treat strategy for H. pylori infection is reasonable for younger patients who have upper GI symptoms, but
not alarm symptoms.
Non-invasive testing can be performed with the use of the urea breath test, fecal antigen test, or serologic test; the serologic test
is the least accurate.
Further eradication therapy should not be considered unless persistent H. pylori infection is confirmed.
The BreathTek® UBT for H. pylori Kit (BreathTek UBT Kit) is intended for use in the qualitative detection
of urease associated with H. pylori in the human stomach and is indicated as an aid in the initial
diagnosis and post-treatment monitoring of H. pylori infection in adult patients. The test may be
used for monitoring treatment if used at least 4 weeks following completion of therapy. For these
purposes, the system utilizes an Infrared Spectrophotometer for the measurement of the ratio of
13
CO2 to 12CO2 in breath samples, in clinical laboratories or point-of-care settings.
The BreathTek UBT Kit is for administration by a health care professional, as prescribed by a physician.
Please see IMPORTANT SAFETY INFORMATION on the back cover.
Important Safety Information
Intended Use:
The BreathTek® UBT for H. pylori Kit
(BreathTek UBT Kit) is intended for use in the
qualitative detection of urease associated
with H. pylori in the human stomach and is
indicated as an aid in the initial diagnosis
and post-treatment monitoring of H. pylori
infection in adult patients. The test may be
used for monitoring treatment if used at least
4 weeks following completion of therapy. For
these purposes, the system utilizes an Infrared
Spectrophotometer for the measurement of
the ratio of 13CO2 to 12CO2 in breath samples, in
clinical laboratories or point-of-care settings.
The BreathTek UBT Kit is for administration
by a health care professional, as prescribed
by a physician.
Warnings and Precautions:
1. For in vitro diagnostic use only. The
Pranactin®-Citric solution is taken orally
as part of the diagnostic procedure.
2. Phenylketonurics: Contains Phenylalanine
(one of the protein components of
Aspartame), 84 mg per dosage unit. (For
reference, 12 ounces of typical diet cola
soft drinks contain approximately 80 mg
of Phenylalanine.)
3. Blood glucose: Use with caution in diabetic
patients. Pranactin-Citric contains Aspartame.
4. A negative result does not rule out the
possibility of H. pylori infection. False
negative results do occur with this
procedure. If clinical signs are suggestive of
H. pylori infection, retest with a new sample
or an alternate methods.
5. False negative test results may be caused by:
• Ingestion of antimicrobials, proton pump
inhibitors, and bismuth preparations
within 2 weeks prior to performing the
BreathTek UBT
• Premature POST-DOSE breath collection
time for a patient with a marginally
positive BreathTek UBT result
• Post-treatment assessment with the
BreathTek UBT less than 4 weeks
after completion of treatment for the
eradication of H. pylori.
6. False positive test results may be caused by:
• Urease associated with other gastric
spiral organisms observed in humans
such as Helicobacter heilmannii
• Achlorhydria.
7. If particulate matter is visible in the
reconstituted Pranactin-Citric solution after
thorough mixing, the solution should not
be used.
8. Hypersensitivity: Patients who are
hypersensitive to mannitol, citric acid or
Aspartame should avoid taking the drug
solution as this drug solution contains
these ingredients.
9. Risk of Aspiration: Use with caution in
patients with difficulty swallowing or who
may be at high risk of aspiration due to
medical or physical conditions.
10. Pregnancy: No information is available
on use of the Pranactin-Citric solution
during pregnancy.
Postmarketing Experience
During post-approval use of the BreathTek UBT,
the following adverse events have been
identified: anaphylactic reaction, hypersensitivity,
rash, burning sensation in the stomach, tingling
in the skin, vomiting and diarrhea. Because
these reactions are reported voluntarily from
a population of uncertain size, it is not always
possible to establish a causal relationship to
drug exposure.
Limitations:
1. The BreathTek UBT should not be used until
4 weeks or more after the end of treatment
for the eradication of H. pylori as earlier
post-treatment assessment may give false
negative results.
2. The specimen integrity of breath samples
and reference gases stored in breath bags
under ambient conditions has not been
determined beyond 7 days.
3. A correlation between the number of
H. pylori organisms in the stomach and
the BreathTek UBT result has not
been established.
Patient Preparation:
1. Remind the patient that Pranactin-Citric
contains phenylalanine (one of the protein
components of Aspartame). Phenylketonurics
restrict dietary phenylalanine.
2. The patient should have fasted at least 1 hour
before administering the BreathTek UBT.
3. The patient should not have taken
antimicrobials, proton pump inhibitors, or
bismuth preparations within 2 weeks prior
to administering the BreathTek UBT.
4. For administration by a healthcare
professional only. Do not provide this kit
to the patient for self-administration.
October 2012
0512L-5944
Please see current Package Insert in inside pocket.
To learn more, call 1-888-637-3835,
or visit www.BreathTek.com.
Medical Device Division of
Otsuka America Pharmaceutical, Inc.
October 2012
©2012 Otsuka America Pharmaceutical, Inc., Rockville, MD
Printed on recycled paper
0512D-5941
Printed in USA