Current approaches to the treatment of gastric ulcer and duodenal ulcer

At the end of the twentieth century. Was a significant step to change the principles of treatment of peptic ulcer (BU)? The success of current approaches to therapy is associated primarily with the use of new antisecretory agents and eradication scheme's Helicobacter pylori (HP). Currently, pharmacotherapy BU includes more than 500 different products and around 1000 combinations. The modern concept of treating a BU provides active therapeutic tactics, including multi-drug schemes and long-term medications may be needed an important component of modern drug therapy of peptic ulcer - a lack of fundamental differences in approaches to the treatment of gastric ulcers and duodenal ulcers.

The main principles of therapy of peptic ulcer disease are:
  • impact on the factors of aggression and / or protection;
  • Etiological therapy;
  • adjustment of medication, taking into account comorbidity;
  • individual patient characteristics (age, body weight, tolerance to medications used, the activity,
  • i.e., the ability to serve themselves);
  • financial capacity of the patient.
  • The main directions in the treatment of peptic ulcer during the exacerbation include:
  • etiological treatment;
  • medical treatment;
  • clinical nutrition;
  • medication;
  • herbal medicine;
  • use of mineral waters;
  • physiotherapy;
  • local treatment for a long time not healing ulcers.
Currently, in the pathogenesis of ulcer, especially duodenal ulcers, attaches great importance to the infectious agent - H. pylori. Epidemiological data from different countries, indicate that 100% of duodenal ulcers and more than 80% of ulcers with localization in the stomach associated with persistence of HP.

Many studies have confirmed that H. pylori treatment reduces the recurrence of gastric ulcer (GU) and duodenal ulcer (DU). The strategy of treating a BU with eradication of HP infection has a distinct advantage over all treatment groups, anti ulcer drugs, as it provides long-term remission of the disease, and possibly a complete cure. H. pylori therapy has been well studied in accordance with the standards of evidence-based medicine Current approaches to diagnosis and treatment of infection H. pylori, meeting the requirements of evidence-based medicine is reflected in the outcome document of the second Maastricht Consensus, adopted in September 2000, the main difference between this instrument of agreement five years ago was a few important points.

  • For the first time to treat the infection H. pylori, and hence the associated diseases charged with the responsibilities of a general practitioner rather than a specialist, a gastroenterologist, as it was accepted earlier. The competence of the gastroenterologist assigned only those cases where treatment of the disease, including using a second-line therapy, was unsuccessful, as well as cases explicitly require intervention specialist.
  • Introduced a two-stage treatment: choosing a first-line regimens, a doctor at once, should plan a backup therapy.
  • It is recommended to use H. pylori therapy in patients with functional dyspepsia, as well as in cases where the planned long-term treatment of nonsteroidal antiinflammatory drugs.
  • Patients with uncomplicated duodenal ulcer are invited to nominate only the recommended courses of Helicobacter therapy, without the subsequent use of antisecretory drugs.
  • The main criterion for selection Helicobacter therapy is its expected performance, providing a high percentage of eradication (80%) rules and guidelines of the Russian Association of Gastroenterology for the treatment of infections with the use of HP Helicobacter therapy.
  • If used regimen is impossible to achieve eradication; a second under this scheme should not be.
  • If you used the scheme has not led to eradication; it means that the bacterium has acquired resistance to one component of treatment regimens.
  • If you use one, then another treatment regimen does not lead to eradication; it is necessary to determine the sensitivity of the strain of HP to the whole spectrum of antibiotics used.

Adoption of the Russian Gastroenterological Association in 1998, national guidelines for diagnosis and treatment of Helicobacter pylori infection and the massive introduction of these doctors have thus far failed to reduce the number of strategic and tactical errors in determining the indications for eradication of H. pylori and the choice of appropriate schemes (see table 1) .

Table 1. Errors in the treatment of HP infection.

What you need to know your doctor is starting Helicobacter therapy? Each general practitioner, particularly with experience of more than five years, will likely have to overcome a psychological barrier before appoint a patient with peptic ulcer disease with antibiotics. To date, doctors, gastroenterologists and internists still in many ways related to Helicobacter therapy at BU. Must be the strict observance scheme H. pylori treatment.

Their effectiveness is proven; they correspond to features of HP and pharmacokinetics of drugs are also known side effects of such therapy.

It is better not to H. pylori therapy in general, rather than spend it wrong - as in this case, quickly develop resistance to a variety of HP components. In this regard, the patient must give details about the upcoming treatment and to seek his agreement to cooperate with the doctor. It is also important to evaluate the possibility of patient material. He should know that, thanks to be expensive, single-treatment can achieve stable remission in patients with duodenal ulcer in 70-80% of cases, while at GU - 50-60%, which ultimately cost effective.

What is the eradication scheme to choose? If you have a stomach ulcer or duodenal against the backdrop of increased acid production, preference should be given to the classic three-part scheme based on the blocker, proton pump (PPI) (omeprazole, etc.) then a transition to the single-dose PPI without antibiotics. Do not use the schema containing Nitroimidazoles (metronidazole, tinidazole), if the history of this group of drugs administered for other indications.

Currently, Russia has witnessed a sharp increase in the number of HP strains that are resistant to nitro imidazole. In view of this urgent problem today is the search for more efficient modes of HP eradication therefore, in recent years a growing interest in the use of macrolides in the treatment of HF-associated diseases. Numerous work has shown the effectiveness of macrolide antibiotics for the treatment of HF. These drugs have a high ability to penetrate cells, intensely highlighted by the mucous membranes (JI), which increases their effectiveness against HP. In addition, macrolide antibiotics, fewer contraindications and side effects, they have a higher rate of eradication than tetracycline, which can also accumulate in the cells. A feature of HP infection is that it is accompanied by giperatsid playin.

In this regard, the majority of macrolide antibiotics, exposed to enhanced hydrolysis and cannot be used. An exception is the clarithromycin resistant to hydrochloric acid.

Therefore, the aim of our study was the development of new schemes of eradication therapy of duodenal ulcer associated with H. pylori, with the use of omeprazole (O), as well as the combination of amoxicillin (A) and clarithromycin (C). We used the following scheme for eradication - ultop (omeprazole) 20 mg twice daily + fromilid (clarithromycin) 500 mg twice daily + hikontsil (amoxicillin) 1000 mg twice a day - a course for seven days. Eradication was 90%. The study showed that the use of fromilida (clarithromycin) to effectively and expediently in the schemes of Helicobacter therapy with PPIs.

These numerous studies and the results of their meta-analysis led to the conclusion that the inclusion of antisecretory drugs in the scheme of eradication of HP-infection not only enhances the eradication of HP in combination with antibiotics, but also accelerates scarring sores makes it easier to eliminate the symptoms of ulcer dyspepsia. As for specific mechanisms to improve eradication rates by taking antisecretory drugs, first of all, with an increase in pH of gastric contents is reduced rate of minimum inhibitory concentration of antibiotics (MIC) and accordingly increases their effectiveness. Furthermore, increase the viscosity of gastric juice and concentration of antibiotic in the gastric contents, thus increasing the exposure time of antibacterial drugs with the bacterium H. pylori. We have investigated the effectiveness of ultopa (omeprazole) - pH> 4 in the gastric single dose of 20 mg has been around for 12-14 h (see Figure 1).

However, the PPI of the first generation did not fully meet the practical needs of clinicians. They are slowly converted into an active form and create the maximum for the eradication antisecretory effect only for the fifth-eighth day of therapy. Among the drugs in this class also includes lansoprazole, pantoprazole, rabeprazole and esomeprazole. They bind to the enzymes of the cell wall of parietal cells - H +, K +-ATPase, and are the most powerful means of controlling gastric acid production.

With the help of pH-metry in HP-negative volunteers studied the action of a new dosage form Loseke ITA. After treatment with this drug antisecretory effect during the day was even more pronounced than with pantoprazole. However, pharmaceutical companies continue to pursue brand new, more effective antisecretory funds, created a new product - Nexium. Antisecretory effect of Nexium is superior to severity, rapidity of onset and duration of exposure such as the effect of omeprazole at standard doses of 20 and 40 mg, pantoprazole 40 mg and lansoprazole 30 mg.

In connection with the above, great interest is the new PPI - Pariet (rabeprazole). In the treatment of gastric ulcer and duodenal recommended taking Pariet 40 mg once daily or 20 mg every 12 h. The most effective, rapid antisecretory and antibacterial agent in the schemes of eradication is Pariet 20 mg twice a day. It should not be appointed within seven days before the start of antibiotic treatment, as in the case of other STIs as well as a reliable antisecretory effect is achieved on the first day of treatment (from the recommendations of the Gastroenterological Association).

Unfortunately, the presence of some patients resistant to antibiotic's HP forcing researchers to develop alternative treatment options for patients suffering from peptic ulcer associated with H. pylori.

Thus, we studied the effectiveness of eradication schemes using redundant antibacterial drugs. The best result of eradication (90%) was achieved using the scheme: De-nol 240 mg twice a day, 14 days + tetracycline 1 g / day, and furazolidone 200 mg twice a day, seven days.

Quite often, the question arises about the need for eradication therapy in elderly and senile age. To date, this can be attributed to the fact that the long-term persistence of HP is developing intestinal metaplasia and atrophy of the gastric mucosa, increases the risk of gastric carcinoma. Age peculiarities of enzymatic activity and atrophic processes in the SB of the gastrointestinal tract and alter the rate of biotransformation of drugs in violation of their absorption. It noted that the concentration of ranitidine is increased in patients over 60 years with comorbidity hepato pancreato biliar region.

"Ahilesovoy heel" of conservative treatment of peptic ulcer disease is well known, the high rate of complications. We prove that eradication of HP completely prevents complications of peptic ulcer. So, in four large studies investigated during peptic ulcer disease in patients in which it manifested bleeding. As I can be seen from the data, any other kind of treatment does not exclude the danger of re-bleeding - within one year after the previous hemorrhage, it recurs in approximately every third patient. In the case of eradication NP bleeding did not recur.

The relapse rate of bleeding after a course of eradication therapy.
Evaluating the effectiveness of eradication is carried out after completion of treatment and aims to identify vegetative and coccoid forms of H. pylori. In the "Recommendations" is clearly defined scheme of this phase of diagnosis:

  • dates - no earlier than four to six weeks after the course protiv helicobacter noy therapy or after treatment of comorbidities any antibiotics or antisecretory means;
  • diagnosis of eradication by using at least two of these diagnostic methods, and using methods that make possible the direct detection of bacteria in biopsy material (bacteriological, histological, urease) necessary to study the two biopsies from the gastric body and a biopsy of the antrum.

You cannot underestimate the role of antacids in the treatment of gastric ulcer and duodenum these drugs, known since ancient times, lower the acidity of gastric juice by chemical interaction with the acid in the stomach. Preference will be given antacids are not absorbed - almagel, Maalox, Aluminium phosphate gel, taltsid, rutatsid. During exacerbation of gastric ulcer and duodenum in treatment, we used rutatsid 500 mg three times a day plus one tablet before bedtime. While taking this remedy the symptoms of gastric dyspepsia disappeared
by the end of the first and second days of treatment. Despite the introduction of modern medical practice inhibitors of gastric secretion, antacids remain important as an effective means of treating patients with gastric ulcer and duodenum.

The treatment must be achieved complete clinical and endoscopic remission, with negative results of the HP-test.

It should be noted that we rarely find cases where the patient has an isolated ulcer. Treatment of comorbidity associated with a number of problems.

Sometimes the conservative therapy is ineffective. This may be due to two factors: the often recurrent course of peptic ulcer and the formation of refractory gastroduodenal ulcers. The analysis revealed the reasons for frequent recurrences within BU, it is - HP infection, use of nonsteroidal anti-inflammatory drugs, the presence of a history of ulcer complications, and low compliance. The factors contributing to the formation of refractory gastroduodenal ulcers, may make the above reasons, as well as latent Zollinger-Ellison syndrome.

In conclusion, we reiterate the critical importance of developing national standards for treatment of gastric ulcer and duodenum and their rapid implementation in practice of a doctor - physician and gastroenterologist. Important arguments in favor of H. pylori treatment were obtained when evaluating the ratio cost / effectiveness. BU is widespread and is characterized by chronic recurrent course. Eradication of H. pylori reduces both direct and indirect costs at BU, without the need for costly maintenance treatment, antisecretory drugs, the risk of repeated exacerbations, complications, and in some cases, surgery.

Thus, modern drug therapy duodenal ulcer and gastric ulcer may provide disease-free for these diseases and to spare patients from complications. In most cases, outpatient treatment is sufficient. The success of therapy depends not only on the optimal use of drug combinations, but also to a large extent, on its implementation with the participation of the patient.

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