Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – Helicobacter pylori testing

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ACUTE
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all patients
1st line – 

Helicobacter pylori testing

Because Helicobacter pylori, an infection considered carcinogenic by the World Health Organization, plays a role in the pathogenesis of most cases of atrophic gastritis, it is reasonable to test for the organism and, if present, eradicate it.[23][72][73]

Atrophic gastritis in the oxyntic mucosa (fundus and corpus), but not necessarily intestinal metaplasia, may improve when re-examined 10 years after H pylori eradication.[126] However, these findings are controversial.[92][93][127]

Plus – Helicobacter pylori eradication therapy

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ACUTE
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all patients
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with Helicobacter pylori infection
Plus – 

Helicobacter pylori eradication therapy

Treatment recommended for ALL patients in selected patient group

An acceptable H pylorieradication regimen is generally defined as one that reliably offers cure rates of at least 90%.[128]

Two first-line quadruple eradication regimens, recommended by guidance, have been shown to have cure rates of at least 90%: (1) proton-pump inhibitor (PPI) (e.g., omeprazole - other PPIs are also suitable) plus amoxicillin plus clarithromycin plus metronidazole; or (2) PPI plus bismuth plus metronidazole plus tetracycline (or doxycycline if tetracycline is not available).[91][129][130][131][132][133][134]

Although some guidelines recommend 10 to 14 days of therapy, 14 days of therapy is generally recommended as increasing the duration of treatment improves the eradication rate without significantly increasing adverse events.[91][129][131][135][136][137][138][139][140][141][142][143]

Patients who fail first-line therapy should be re-treated with regimens that do not include previously used antibiotics, except for amoxicillin and tetracycline as resistance to later antibiotics is rare.[21][91][129] Those with a penicillin allergy should be considered for allergy testing. 

Second-line regimens after first-line regimen failure include: (1) PPI plus amoxicillin plus levofloxacin; (2) high-dose PPI plus high-dose amoxicillin; (3) or PPI plus rifabutin plus amoxicillin.[21][91][129] 

Fourteen days of therapy is recommended for these regimens, although the rifabutin-based regimen may be given for 10 to 14 days.[129][144][145]

High-dose dual therapy, defined as the administration of a high dose of a PPI plus a high dose of amoxicillin, is effective following first-line therapy failure (70% to 89%), and circumvents the issue of clarithromycin, metronidazole, and levofloxacin resistance.[147][148]

Rifabutin-based regimens are effective rescue therapies as H pyloriresistance to this commonly used anti-tuberculosis drug is uncommon.[91][98][73][128][129][131][149][150][151][152][153][154] Although myelotoxicity was observed in 2% of treated patients, all of them recovered without increased susceptibility to infection.[155]

Standard first-line empirical initial treatment for H pylori infection is triple therapy consisting of a PPI, amoxicillin, and clarithromycin for 14 days.[91][129] However, treatment success with this regimen is presently <80%, in both the US and Europe, primarily related to an increase in the prevalence of clarithromycin resistance and poor treatment adherence; evidence suggests that this regimen should no longer be recommended.[130][156]

Resistance to other antibiotics, traditionally used in H pylorieradication regimens, has also increased. In the US, resistance to metronidazole is 20% and to levofloxacin 31%. Fortunately, antibiotic resistance to tetracycline and amoxicillin is low to rare.[156][157] Poor treatment adherence is related to complex treatment regimens and adverse effects to antibiotics. 

Treatment success (or failure) should be confirmed using urea breath test, stool antigen test, or biopsy with immunohistochemistry or rapid urease test.[128] The tests should be performed at least four weeks after completion of the eradication regimen. PPIs, which are bacteriostatic against H pylori, should be withheld for one to two weeks prior to testing.[129][158][159][160] There is some evidence that certain stool antigen tests that use monoclonal antibodies may be reliable even in the presence of PPIs.[161]

Primary options

omeprazole: 20 mg orally twice daily

and

amoxicillin: 1000 mg orally twice daily

and

clarithromycin: 500 mg orally twice daily

and

metronidazole: 500 mg orally twice daily

OR

omeprazole: 20 mg orally twice daily

and

bismuth subsalicylate: 300 mg orally four times daily

and

metronidazole: 400 mg orally four times daily; or 500 mg three to four times daily

-- AND --

tetracycline: 500 mg orally four times daily

or

doxycycline: 100 mg orally (delayed-release) once daily

Secondary options

omeprazole: 20 mg orally twice daily

and

amoxicillin: 1000 mg orally twice daily

and

levofloxacin: 500 mg orally once daily

OR

omeprazole: 40 mg orally three or four times daily

and

amoxicillin: 1000 mg orally three times daily; or 750 mg four times daily

OR

omeprazole: 20 mg orally twice daily

and

amoxicillin: 1000 mg orally twice daily

and

rifabutin: 300 mg orally once daily

Plus – parenteral vitamin B12

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ACUTE
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all patients
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with cobalamin deficiency
Plus – 

parenteral vitamin B12

Treatment recommended for ALL patients in selected patient group

Cobalamin deficiency can be treated with parenteral (i.e., intramuscular) cyanocobalamin (vitamin B12).

Primary options

cyanocobalamin: 1000 micrograms intramuscularly once daily for 1 week, followed by 1000 micrograms once weekly for 4 weeks, followed by 1000 micrograms once monthly for remainder of patient's life

Plus – iron replacement therapy + ascorbic acid

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ACUTE
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all patients
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with iron deficiency
Plus – 

iron replacement therapy + ascorbic acid

Treatment recommended for ALL patients in selected patient group

Oral iron, along with ascorbic acid (vitamin C), is used to treat iron deficiency.

Reducing substances such as ascorbic acid promotes the conversion of Fe3+ to Fe2+, thereby improving solubility and absorption.

Traditionally, oral ferrous sulfate is prescribed; there is evidence to suggest that once daily or alternate daily dosing regimens may optimise iron absorption and decrease adverse effects compared with standard regimens (detailed above).[162]

Parenteral iron can be given intramuscularly but intravenously is the preferred method.[168][169]

The iron deficit is calculated based on the premise that 1 g of haemoglobin contains 3.3 mg of elemental iron.

Primary options

ferrous sulfate: 325 mg orally three times daily

or

ferrous fumarate: 325 mg orally three times daily

or

ferrous gluconate: 325 mg orally three times daily

-- AND --

ascorbic acid: 250 mg orally once daily

Secondary options

sodium ferric gluconate complex: consult specialist for guidance on dose

OR

iron dextran: consult specialist for guidance on dose

OR

iron sucrose: consult specialist for guidance on dose

OR

ferumoxytol: consult specialist for guidance on dose

OR

ferric carboxymaltose: consult specialist for guidance on dose

Plus – calcium + vitamin D

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ACUTE
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all patients
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with calcium deficiency
Plus – 

calcium + vitamin D

Treatment recommended for ALL patients in selected patient group

There are no specific recommendations regarding prevention or treatment of calcium deficiency in patients with achlorhydria. Based upon recommendations for reducing fracture risk in older people, it would seem reasonable to give the dose used for this indication with a target serum 25-hydroxyvitamin D concentration of >50 nanomol/L (>20 nanograms/mL).

Calcium and vitamin D deficiency may be monitored by periodic serum 25-hydroxyvitamin D as well as bone mineral density testing.[170][171][172]

Primary options

calcium carbonate: 1000-1500 mg orally once daily

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and

ergocalciferol: 800 units orally once daily

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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