An optimized clarithromycin-free 14-day triple therapy for Helicobacter pylori eradication achieves high cure rates in Uruguay.

BACKGROUND: Strong acid inhibition increases cure rates with triple therapy and 14-day are more effective than 7-day treatments. The combination of amoxicillin plus metronidazole at full doses has been shown to overcome metronidazole resistance and to achieve good eradication rates even in patients harboring resistant strains. No previous studies have been reported in Latin-America with this optimized triple-therapy scheme. AIMS: The aim of the present study was to assess the eradication rate and tolerance of a new first-line treatment regimen associating strong acid inhibition, amoxicillin and metronidazole. METHODS: Patients from the Clínica de Gastroenterología of the Hospital de Clínicas (Montevideo, Uruguay) were included. Hp status was mainly assessed by at least one of the following: histologyor urea breath test (UBT). A 14-day treatment was prescribed comprising esomeprazole 40mg twice a day plus amoxicillin 1g and metronidazole 500mg, both three times a day. H. pylori cure was assessed by UBT. RESULTS: Forty-one patients were enrolled. Mean age was 53.3±13 years and 17.1% of patients were male. Main indications for treatment were: functional dyspepsia (27.5%), gastritis (45%), gastric or duodenal erosions (20%), gastric ulcer (5%) and intestinal metaplasia (2.5%). H. pylori eradication was achieved in 33 of the 37 patients who returned for follow-up. Eradication rates were 80.5% (95% CI: 68.4-92.6) by intention-to-treat (ITT) analysis and 89.2% (95% CI; 79.2-99.2) per protocol (PP). No major side effects were reported; 26 patients (65.8%) complained of mild side effects (nausea, diarrhea and headache). CONCLUSIONS: Cure rates of this triple therapy including esomeprazole, amoxicillin and metronidazole were 81% per ITT and the treatment was well tolerated. These optimal results with a simple clarithromycin-free triple therapy are better than described for standard triple therapy but there is still room for improvement to reach the desired target of 90% per ITT.

Resultados en la práctica clínica del tratamiento de la hepatitis crónica por virus B con tenofovir y entecavir / Results in clinical practice of treatment of chronic hepatitis b virus with tenofovirand entecavir

Actualmente hay pocos datos sobre los resultados obtenidos con tenofovir y entecavir en la práctica clínica. Objetivo: Valorar la respuesta viral y la seguridad de tenofovir y entecavir en un periodo de 5 años. Material y métodos: Estudio observacional en donde se incluyó a todos los pacientes con hepatitis crónica por virus B que iniciaron tratamiento con tenofovir o entecavir desde enero de 2008 hasta diciembre de 2012. Resultados: De un total de 70 pacientes: 42 (60%) en tratamiento con entecavir y 28 (40%) con tenofovir. Un 75,7% eran hombres, con una edad media de 53 (DE 14) años. Un 70% eran caucásicos. Se realizó biopsia hepática en 46 pacientes (F0 8,7%; F1 6,5%; F2 26,1%; F3 43,5% y F4 15,2%). El 51,4% eran naïve. Del grupo de pacientes previamente tratados, un 17,6% había recibido interferón; un 26,4% interferón inicialmente y luego análogos; y un 55,8% otros análogos de los nucleósidos o de los nucleótidos. El tiempo de seguimiento fue de 36 (DE 12) meses. El DNA del VHB inicial medio era de 31.570.006 UI/mL (rango 24-1.100.000.000 UI/mL).Todos ellos, excepto 3, presentaron un DNA indetectable al año del tratamiento. De los 10 con HBeAg+, 2 de ellos presentaron seroconversión. Los valores de creatinina y la estimación del filtrado glomerular (EFG) fueron de 0,9 (DE 0,3) mg/dL y de 93,92 ml/min/1,73 m² (DE 21,92) al inicio y creatinina 0,93 (DE 0,27) mg/dL y EFG 91,7392 ml/min/1,73 m² (DE 21,38) al año de seguimiento. Conclusiones: Entecavir y tenofovir son eficaces y seguros en la práctica clínica en pacientes con hepatitis crónica por virus B.

The current first line treatment for chronic hepatitis B virus is with entecavir andtenofovir. However, there are few data regarding the results obtained from these treatmentsin clinical practice. Objective: To assess viral response and safety of treatment with entecavir and tenofovir in a5-year follow-up. Material and methods: Observational study on patients with chronic hepatitis B virus who begantreatment with tenofovir or entecavir between January 2008 and December 2012. Results: Seventy patients were included; 42 (60%) were treated with entecavir and 28 (40%)with tenofovir. Of these, 75.7% were men, with an average age of 53 (SD ± 14) years, and mostwere white (70%). A liver biopsy was performed on 46 patients (F0 8.7%; F1 6.5%; F2 26.1%;F3 43.5% and F4 15.2%). Of all the patients, 51.4% were treatment naïve, and of the groupof previously treated patients, 17.6% had received interferon; 26.4% had received interferonfollowed by one or more analogues; and 55.8% had received other nucleoside or nucleotideanalogues.The time of follow-up was 36 (SD ± 12) months. The average initial DNA was 31,570,006UI/mL (range 24-1,100,000,000 UI/mL). All except 3 presented undetectable DNA after oneyear of treatment. Ten patients were HBeAg-positive at the beginning of the treatment and 2seroconverted. At the beginning of the treatment, creatinine was 0.9 (SD ± 0.3) mg/dL and theestimated glomerular filtration rate (eGFR) was 93.92 ml/min/1.73 m²(DE 21.92); both keepingstable after a year of treatment (creatinine levels 0.93 SD ± 0.27 mg/dL, eGFR 91.7392 SD± 21.38 ml/min/1.73 m²). Conclusions: Entecavir and tenofovir are safe and effective in clinical practice for the treatmentof chronic hepatitis B virus, both in treatment-naïve patients and in those previously treated.

Effects of a multidisciplinary approach on the effectiveness of antiviral treatment for chronic hepatitis C.

UNLABELLED:  Background. Despite the introduction of direct antiviral agents, pegylated interferon remains the mainstay of treatment for chronic hepatitis C. However, pegylated interferon is associated with a high rate of severe adverse events and decreased quality of life. Specific interventions can improve adherence and effectiveness. We aimed to determine whether implementing a multidisciplinary approach improved outcomes in the treatment of chronic hepatitis C. MATERIAL AND METHODS: We analyzed consecutive patients treated with pegylated interferon plus ribavirin between August 2001 and December 2011. We compared patients treated before and after the implementation of a multidisciplinary approach in 2007. We compared the baseline demographic and clinical characteristics and laboratory findings between groups, and used bivariate logistic regression models to detect factors involved in attaining a sustained virological response, calculating the odds ratios with their respective 95% confidence intervals. To evaluate the effect of the multidisciplinary team, we fitted a multivariate logistic regression model to compare the sustained virological response after adjusting for unbalanced variables and predictive factors. RESULTS: We included 514 patients [228 (44.4%) in the pre-intervention cohort]. Age, viral genotype, previous treatment, aspartate transaminase, ferritin, and triglyceride were prognostic factors of sustained virological response. After adjusting for prognostic factors, sustained virological response was higher in the multidisciplinary cohort (58 vs. 48%, p = 0.038). Despite higher psychiatric comorbidity and age in the multidisciplinary cohort, we observed a trend toward a lower rate of treatment abandonment in this group (2.2 vs. 4.9%, p = 0.107). CONCLUSION: Multidisciplinary management of chronic hepatitis C improves outcomes.

Has H. pylori prevalence in bleeding peptic ulcer been underestimated? A meta-regression.

OBJECTIVES: It has been suggested that prevalence of Helicobacter pylori (Hp) in peptic ulcer bleeding (PUB) is lower than that in non-complicated ulcers. As Hp infection is elusive in PUB, we hypothesized that this low prevalence could be related to an insufficiently intensive search for the bacteria. The aim of the study was to evaluate whether the prevalence of Hp in PUB depends on the diagnostic methods used in a given study. METHODS: A systematic review was performed of studies assessing the prevalence of Hp infection in patients with PUB. Data were extracted in duplicate. Univariate and multivariate random-effects meta-regression analyses were performed to determine the factors that explained the differences in Hp prevalence between studies. RESULTS: The review retrieved 71 articles, including 8,496 patients. The mean prevalence of Hp infection in PUB was 72%. The meta-regression analysis showed that the most significant variables associated with a high prevalence of Hp infection were the use of a diagnostic test delayed until at least 4 weeks after the PUB episode-odds ratio: 2.08, 95% confidence interval: 1.10-3.93, P=0.024-and a lower mean age of patients-odds ratio: 0.95 per additional year, 95% confidence interval: 0.92-0.99, P=0.008. CONCLUSIONS: Studies that performed a delayed test and those including younger patients found a higher prevalence of Hp, approaching that recorded in cases of non-bleeding ulcers. These results suggest that the low prevalence of Hp infection described in PUB may be related to the methodology of the studies and to patients' characteristics, and that the true prevalence of Hp in PUB is still to be determined. Our data also support the recent recommendations of the International Consensus on Non-Variceal Upper Gastrointestinal Bleeding regarding the performance of a delayed diagnostic test when Hp tests carried out during the acute PUB episode are negative.