幽門螺旋桿菌之治療. 臨床藥物治療學50 THE JOURNAL OF TAIWAN PHARMACY Vol.32 No.4 Dec 中山醫學大學附設醫院藥劑科藥師林政仁中山醫學大學醫學系助理教授李建瑩

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1 幽門螺旋桿菌之治療中山醫學大學附設醫院藥劑科藥師林政仁中山醫學大學醫學系助理教授李建瑩臨床藥物治療學50 THE JOURNAL OF TAIWAN PHARMACY Vol.32 No.4 Dec 摘要 (Proton-pump inhibitors) clarithromycin amoxicillin ( metronidazole) 20% 84.3% PPI amoxicillin PPI tetracycline metronidazole PPI amoxicillin levofloxacin Helicobacter pylori Triple therapy Sequential therapy Quadruple therapy High-dose dual therapy 壹前言 (Helicobacter pylori) 2005 Marshall Warren ( ) ( ) 貳治療 ( 表一 ) 一標準三合一療法 (Triple therapy) clarithromycin (< 15%) (proton pump inhibitor,

2 藥學雜誌 PPI) clarithromycin amoxicillin ( penicillin metronidazole) 3 PPI lansoprazole 30 mg omeprazole 20 mg pantoprazole 40 mg rabeprazole 20 mg esomeprazole 40 mg Clarithromycin 500 mg amoxicillin 1000 mg ( metronidazole 500 mg) PPI clarithromycin amoxicillin PPI clarithromycin metronidazole % % (RR % CI ; NNT 11, 95% CI 9-14 ) % % (RR 1.21, 95% CI ; NNTH 31, 95% CI ) 4 ( ) 5 臨床藥物治療學處方組成療程滅菌成功率患者沒有 penicillin 過敏 (Triple therapy) % 3 PPI + clarithromycin 500 mg + amoxicillin 1000 mg (Sequential Therapy) PPI + amoxicillin 1000 mg 5 PPI + clarithromycin 500 mg + metronidazole 500 mg ( tinidazole) % 9 PPI (rabeprazole 20 mg) + amoxicillin 750 mg (Concomitant therapy) % 10 PPI (esomeprazole 40 mg) + amoxicillin 1000 mg + clarithromycin 500 mg + metronidazole 500 mg 患者有 penicillin 過敏 (Triple therapy) % 3 PPI + clarithromycin 500 mg + metronidazole 500 mg Clarithromycin 抗藥性高 (> 15%) 的地區 (Sequential Therapy) 10 96% 6 PPI + amoxicillin 1000 mg 5 PPI + levofloxacin 250 mg + metronidazole500 mg ( tinidazole) 5 第一線治療失敗 % 3 PPI + Bismuth subsalicylate 525 mg+ metronidazole 250 mg + tetracycline 500 mg % 3 PPI + Bismuth subcitrate 420 mg+ metronidazole 375 mg + tetracycline 375 mg Levofloxacin 10 94% 12 Levofloxacin 500 mg + PPI (rabeprazole 20 mg)+ amoxicillin 750 mg 32 4 Dec ,6,7,9,10,12 表一幽門螺旋桿菌的治療 % 6,7

3 繼續教育臨床藥物治療學表二幽門螺旋桿菌治療藥品常見副作用 ( 最常見副作用是由於 clarithromycin 與 metronidazole 產生味覺異常 ( 金屬味 )) 5 藥品常見副作用 clarithromycin metronidazole disulfiram-like amoxicillin tetracycline levofloxacin QT 二系列性治療 (Sequential Therapy) Zullo PPI amoxicillin 5 5 PPI clarithromycin metronidazole ( tinidazole) penicillin clarithromycin (> 15%) levofloxacin (250 mg ) % (95% CI 82.1%-86.4%) (RR 1.21, 95% CI ; NNT 6, 95% CI 5%-7%) 7 ( a multicentre, randomised trial) 14 ( lansoprazole 30 mg amoxicillin 1 g lansoprazole 30 mg clarithromycin 500 mg metronidazole 500 mg ) % (95% CI ) % (95% CI ) 52 THE JOURNAL OF TAIWAN PHARMACY Vol.32 No.4 Dec levofloxacin clarithromycin amoxicillin (96 vs 81%) 三高劑量二合一療法 (High-dose Dual Therapy) amoxicillin ph amoxicillin PPI amoxicillin rabeprazole 20 mg amoxicillin 750 mg % (95% CI, %) % (95% CI, %) % (95% CI, %) 89.3% (95% CI, %) % (95% CI, %) 7 levofloxacin 78.6% (95% CI, %) 9 四合併療法 (Concomitant therapy) PPI (esomeprazole) amoxicillin clarithromycin metronidazole 7 (93.0%; 95% CI: 88.3%-97.7%) 10 (92.3%; 95% CI 87.5%-97.1%) (p = 0.83) 10 五標準四合一療法 (Quadruple therapy) clarithromycin (> 15%)

4 藥學雜誌 PPI ( bismuth subcitrate bismuth subsalicylate) tetracycline metronidazole % 90% 3 六以 levofloxacin 為基礎之三合一療法 metronidazole 51% amoxicillin levofloxacin 2% 15% 11 PPI amoxicillin levofloxacin 臨床藥物治療 metronidazole 學 12 參總結 32 4 Dec Tratment of Helicobacter Pylori Infection Zheng-Ren Lin 1, Chien-Ying Lee 2 Department of Pharmacy, Chung Shan Medical University Hospital 1 Department of Pharmacology, Chung Shan Medical University 2 Abstract Currently, the first-line therapy for Helicobacter pylori infection is standard triple therapy, consisting of a proton pump inhibitor, clarithromycin and amoxicillin. But in recent years, with the increase in drug- resistant strains of Helicobacter pylori sterilization success rate has declined the trend, so there are many new treatments being developed. Currently, most treatment guidelines triple therapy is still the first choice for Helicobacter pylori infection, but this treatment failure rates in many parts of the world up to 20%. Series of first-line therapy is another method of treatment, sterilization succes rate of 84.3%, while high-dose dual therapy and concomitant therapy have been developed and achieve a high eradication rate. The second-line therapy, most guidelines suggest a quadruple therapy. Recently, a triple therapy with the combination of a PPI, levofloxacin and amoxicillin and also achieve a high eradication rate.

5 繼續教育參考資料 : 臨床藥物治療學1. Medeiros JA, Pereira MI: The use of probiotics in Helicobacterpylori eradication therapy. J Clin Gastroenterol 2013; 47: Huang AH, Sheu BS, Yang HB, et al: Impact of Helicobacterpylori antimicrobial resistance on the outcome of 1-week lansoprazole-based triple therapy. J Formos Med Assoc2000; 99: Chey WD, Wong BCY: American College of Gastroenterology Guideline on the Management of Helicobacter pylori Infection. Am J Gastroenterol 2007; 102: Yuan Y, Ford AC, Khan KJ, et al: Optimum duration of regimens for Helicobacter pylori eradication. Cochrane Database Syst Rev. 2013;12:CD Crowe SE: Treatment regimens for Helicobacter pylori. UpToDate online. Available at (cited:12/14/2015) 6. Romano M, Cuomo A, Gravina AG, et al: Empirical levofloxacin-containing versus clarithromycin-containing sequential therapy for Helicobacter pylori eradication: a randomised trial. Gut 2010; 59: Gatta L, Vakil N, Vaira D, et al: Global eradication ratesfor Helicobacter pylori infection: systematic review and 54 THE JOURNAL OF TAIWAN PHARMACY Vol.32 No.4 Dec meta-analysis of sequential therapy. BMJ 2013; 347: f Liou JM, Chen CC, Chen MJ, et al: Sequential versus triple therapy for the first-line treatment of Helicobacter pylori: a multicentre, open-label, randomised trial.lancet 2013; 381: Yang JC, Lin CJ, Wang HL, et al: High-dosedual therapy is superior to standard first-line or rescue therapy for Helicobacter pylori infection. Clin Gastroenterol Hepatol 2015; 13: e5 10. Wu DC, Hsu PI, Wu JY, et al: Sequential and concomitanttherapy with four drugs is equally effective for eradicationof H. pylori infection. Clin Gastroenterol Hepatol 2010; 8: Wu DC, Hsu PI, Chen A, et al: Randomized comparison oftwo rescue therapies for Helicobacter pylori infection. Eur JClin Invest 2006; 36: Nista EC, Candelli M, Cremonini F, et al: Levofloxacin based triple therapy vs. quadruple therapy in second-line Helicobacter pylori treatment: a randomized trial. Aliment Pharmacol Ther 2003; 18:

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幽門螺旋桿菌之治療. 臨床藥物治療學50 THE JOURNAL OF TAIWAN PHARMACY Vol.32 No.4 Dec 中山醫學大學附設醫院藥劑科藥師林政仁 中山醫學大學醫學系助理教授李建瑩

幽門螺旋桿菌之治療. 臨床藥物治療學50 THE JOURNAL OF TAIWAN PHARMACY Vol.32 No.4 Dec 中山醫學大學附設醫院藥劑科藥師林政仁中山醫學大學醫學系助理教授李建瑩