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1 Helicobacter pylori testing and eradication in adults bring together everything NICE says on a topic in an interactive flowchart. are interactive and designed to be used online. They are updated regularly as new NICE guidance is published. To view the latest version of this NICE Pathway see: NICE Pathway last updated: 03 October 2017 This document contains a single flowchart and uses numbering to link the boxes to the associated recommendations. Page 1 of 10

2 Page 2 of 10

3 1 Suspected H. pylori infection No additional information 2 H. pylori testing Test for H. pylori using a carbon-13 urea breath test or a stool antigen test, or laboratory-based serology where its performance has been locally validated. Perform re-testing for H. pylori using a carbon-13 urea breath test. (There is currently insufficient evidence to recommend the stool antigen test as a test of eradication. 1 ) Do not use office-based serological tests for H. pylori because of their inadequate performance. Quality standards The following quality statement is relevant to this part of the interactive flowchart. in adults 3. Testing conditions for Helicobacter pylori 3 First-line treatment Offer people who test positive for H. pylori a 7-day, twice-daily course of treatment with: amoxicillin and either clarithromycin or metronidazole. Choose the treatment regimen with the lowest acquisition cost, and take into account previous exposure to clarithromycin or metronidazole. Offer people who are allergic to penicillin a 7-day, twice-daily course of treatment with: clarithromycin and metronidazole. Page 3 of 10

4 1 This refers to evidence reviewed in Page 4 of 10

5 Offer people who are allergic to penicillin and who have had previous exposure to clarithromycin a 7-day, twice-daily course of treatment with: bismuth and metronidazole and tetracycline. For the assessment of allergy to beta-lactam antibiotics and referral to specialist care, see NICE's recommendations on drug allergy. Discuss treatment adherence with the person and emphasise its importance. Proton pump inhibitor doses for H. pylori eradication therapy Proton pump inhibitor Dose Esomeprazole 20 mg Lansoprazole 30 mg Omeprazole mg Pantoprazole 40 mg Rabeprazole 20 mg 4 Eradication successful No additional information 5 Managing uninvestigated dyspepsia See / Managing uninvestigated dyspepsia in adults Page 5 of 10

6 6 Managing peptic ulcer disease See / Managing peptic ulcer disease in adults 7 Managing functional dyspepsia See / Managing functional dyspepsia in adults 8 Eradication unsuccessful No additional information 9 Second-line treatment Offer people who still have symptoms after first-line eradication treatment a 7-day, twice-daily course of treatment with: amoxicillin and either clarithromycin or metronidazole (whichever was not used first-line). Offer people who have had previous exposure to clarithromycin and metronidazole a 7-day, twice-daily course of treatment with: amoxicillin and a quinolone or tetracycline (whichever has the lowest acquisition cost). Offer people who are allergic to penicillin (or who have not had previous exposure to a quinolone) a 7-day, twice-daily course of treatment with: metronidazole and levofloxacin. Offer people who are allergic to penicillin and who have had previous exposure to a quinolone: Page 6 of 10

7 bismuth and metronidazole and tetracycline. For the assessment of allergy to beta-lactam antibiotics and referral to specialist care, see NICE's recommendations on drug allergy. Proton pump inhibitor doses for H. pylori eradication therapy Proton pump inhibitor Dose Esomeprazole 20 mg Lansoprazole 30 mg Omeprazole mg Pantoprazole 40 mg Rabeprazole 20 mg 10 Eradication unsuccessful No additional information 11 Specialist advice and referral Seek advice from a gastroenterologist if eradication of H. pylori is not successful with secondline treatment. Consider referral to a specialist service for people with H. pylori that has not responded to second-line eradication therapy. Page 7 of 10

8 Glossary H. pylori Helicobacter pylori H2RA H 2 receptor antagonist NSAID non-steroidal anti-inflammatory drug PPI proton pump inhibitor Sources Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management (2014) NICE guideline CG184 Your responsibility Guidelines The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian. Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They Page 8 of 10

9 should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties. Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. Technology appraisals The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian. Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. Medical technologies guidance, diagnostics guidance and interventional procedures guidance The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the Page 9 of 10

10 interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties. Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. Page 10 of 10

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