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. 31 2016 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 1983 1 2 ( ) ( ) 貳 治療 ( 表一 ) 一 標準三合一療法 (Triple therapy) clarithromycin (< 15%) (proton pump inhibitor,
藥學雜誌 129 51 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) 10 14 PPI clarithromycin amoxicillin PPI clarithromycin metronidazole 7 72.9% 14 81.9% (RR 0.66 95% CI 0.60-0.74; NNT 11, 95% CI 9-14 ) 7 15.5% 14 19.4% (RR 1.21, 95% CI 1.06-1.37; NNTH 31, 95% CI 18-104) 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) 7-14 70-85% 3 PPI + clarithromycin 500 mg + amoxicillin 1000 mg (Sequential Therapy) PPI + amoxicillin 1000 mg 5 PPI + clarithromycin 500 mg + metronidazole 500 mg ( tinidazole) 5 14 95.3% 9 PPI (rabeprazole 20 mg) + amoxicillin 750 mg (Concomitant therapy) 7 93.0% 10 PPI (esomeprazole 40 mg) + amoxicillin 1000 mg + clarithromycin 500 mg + metronidazole 500 mg 患者有 penicillin 過敏 (Triple therapy) 7-14 70-85% 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 10-14 75-90% 3 PPI + Bismuth subsalicylate 525 mg+ metronidazole 250 mg + tetracycline 500 mg 10-14 75-90% 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. 31 2016 3,6,7,9,10,12 表一幽門螺旋桿菌的治療 10-14 84.3-90.7% 6,7
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 ) 6 84.3% (95% CI 82.1%-86.4%) (RR 1.21, 95% CI 1.17-1.25; 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 ) 14 14 90 7% (95% CI 87 4-94 0) 14 82 3% (95% CI78 0-86 6) 52 THE JOURNAL OF TAIWAN PHARMACY Vol.32 No.4 Dec. 31 2016 8 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 14 95.3% (95% CI, 91.9-98.8%) 10 85.3% (95% CI, 79.6-91.1%) 5 80.7% (95% CI, 74.3-87.1%) 89.3% (95% CI, 80.9-97.6%) 10 51.8% (95% CI, 38.3-65.3%) 7 levofloxacin 78.6% (95% CI,67.5-89.7%) 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%)
藥學雜誌 129 53 PPI ( bismuth subcitrate bismuth subsalicylate) tetracycline metronidazole 10 14 75% 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. 31 2016 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.
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