DGI:Helicobacter Pylori/Therapie: Difference between revisions

Revision as of 12:00, 14 June 2021

Therapie

Indikation zur Behandlung

Bei peptischen Ulcus ventriculi oder Ulcus duodeni
Bei gastralen MALT-Lymphomen
Bei diffus-großzelligem B-Zell-Lymphom des Magens
B-Gastritis zur Karzinomprophylaxe, insbesondere bei positiver Familienanamnese
Bei Nachweis von Adenomen oder hyperplastischen Magenpolypen
Bei Patienten mit einer ITP, Morbus Menier oder einer lymphozytären Gastritis
Vor Antikoagulation bzw. Dauermedikation mit ASS oder NSAR bei gleichzeitiger Ulcusanamnese

Behandlung kann angeboten werden

Bei Patienten mit asympt. H. pylori-Gastritis
Bei SSRI-Komedikation
Bei anderen extragastralen Manifestationen
Bei H. pylori -Gastritis und Eisenmangelanämie

Zurückhaltende/ keine Indikation

Dyspepsie
Refluxsymptome oder eine Refluxösophagitis
Bei ungeklärter Eisenmangelanämie

Antibiotikatherapien

Der Erfolg der Eradikationstherapie von H. pylori hängt von den Resistenzen gegenüber den Antibiotika ab.

Bei einer Resistent gegenüber Metronidazol von rund 40% in Deutschland, verbietet sich eine Eradikationstherapie, welche Metronidazol enthält (Ausnahme die Bismuth-Quadrupeltherapie) Die Resistenzlage gegenüber Clarithromycin ist in Deutschland ebenfalls problematisch und beträgt aktuell rund 20%. Folgendes Vorgehen wird empfohlen:

Erstlinientherapie mit der Bismuth-Quadrupeltherapie, falls eine Clarithromycin Resistenz anzunehmen ist.
Falls eine Clarithromycin Resistenz unwahrscheinlich ist, wird die Französische Tripeltherapie empfohlen
Falls die Eradikation nicht erfolgreich war, dann Zweitlinientherapie mit der Bismuth-Quadrupeltherapie oder mit der Fluorochinolon-Tripeltherapie
Falls die Eradikation erneut nicht erfolgreich sein sollte dann Resistenztestung und entsprechende Therapie

Erstlininientherapien		Dauer
Bismuth-Quadrupeltherapie	PPI 2 x tgl. 1 Standarddosis Bismuth-Kaliumsalz/ Tetracyclin/ Metronidazol 4 x 3 Hartkapseln	10 Tage
Französische Tripeltherapie	PPI 2 x tgl. 1 Standarddosis Amoxicillin 2-3 x 1000 mg Clarithromycin 2 x 500 mg	14 Tage
Alternative Zweitlinientherpapie
Fluorchinolon-Tripeltherapie I	PPI 2 x tgl. 1 Standarddosis Levofloxacin 500 mg oder Moxifloxacin 400 mg 1 x tgl. Amoxicillin 2 x 1000 mg	10-14 Tage
Drittlinientherapie	Nach Resistenzbestimmung
Erstlinientherapien		Dauer
Äquivalenzdosierungen der Protonenpumpenhemmer (PPI)
	Omeprazol 20 mg Esomeprazol 20 m Pantoprazol 40 mg Lansoprazol 30 mg Rabeprazol 20 mg

Zusammenfassen aufgrund der zunehmenden Resistenzen, v.a. gegenüber Metronidazol, Clarythromycin und Levofloxazin, kommt der Bismuth-Quadrupel-Therapie eine überragende Bedeutung zu. Einschränkungen sind der Preis, die hohe Zahl von Tabletten und die Verträglichkeit. Aus der Perspektive der Antibiotikaresistenz ist dieses Schema jedoch als effektiver im Vergleich zu den anderen Kombinationen einzuschätzen.

Neben der Kontrolle des Eradikationserfolgs ist bei U. ventriculi eine endoskopische Kontrolle wichtig. Durch die Therapie sollte das Ulcus/die Ulcera abheilen. Tun sie dieses nicht, so muss erneut endoskopiert werden inklusiv Biopsieentnahme. Hierbei muss das Vorliegen/die Entwicklung eines Malignoms ausgeschlossen werden.

@@ Line 2: / Line 2: @@
 '''Indikation zur Behandlung'''
-* Bei peptischen Ulcus ventriculi oder Ulcus duodeni
+*Bei peptischen Ulcus ventriculi oder Ulcus duodeni
-* Bei gastralen MALT-Lymphomen
+*Bei gastralen MALT-Lymphomen
-* Bei diffus-großzelligen B-Zell-Lymphom des Magens
+*Bei diffus-großzelligem B-Zell-Lymphom des Magens
-* B-Gastritis zur Karzinomprophylaxe, insbesondere bei positiver Familienanamnese
+*B-Gastritis zur Karzinomprophylaxe, insbesondere bei positiver Familienanamnese
-* Bei Nachweis von Adenomen oder hyperplastischen Magenpolypen
+*Bei Nachweis von Adenomen oder hyperplastischen Magenpolypen
-* Bei Patienten mit einer ITP, Morbus Menier oder einer lymphozytären Gastritis
+*Bei Patienten mit einer ITP, Morbus Menier oder einer lymphozytären Gastritis
-* Vor Antikoagulation bzw. Dauermedikation mit ASS oder NSAR bei gleichzeitiger Ulcusanamnese
+*Vor Antikoagulation bzw. Dauermedikation mit ASS oder NSAR bei gleichzeitiger Ulcusanamnese
 '''Behandlung kann angeboten werden'''
-* Bei Patienten mit asympt. Hp-Gastritis
+*Bei Patienten mit asympt. H. pylori-Gastritis
-* Bei SSRI-Komedikation
+*Bei SSRI-Komedikation
-* Bei anderen extragastralen Manifestationen
+*Bei anderen extragastralen Manifestationen
-* Bei Hp-Gastritis und Eisenmangelanämie
+*Bei H. pylori -Gastritis und Eisenmangelanämie
 '''Zurückhaltende/ keine Indikation'''
-* Dyspepsie
+*Dyspepsie
-* Refluxsymptome oder eine Refluxösophagitis
+*Refluxsymptome oder eine Refluxösophagitis
-* Bei ungeklärter Eisenmangelanämie
+*Bei ungeklärter Eisenmangelanämie
-===== Antibiotikatherapien =====
+=====Antibiotikatherapien=====
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+Der Erfolg der Eradikationstherapie von H. pylori hängt von den Resistenzen gegenüber den Antibiotika ab.
-|+
-| style="width:120.45000000000002pt;" width="161" |<span style="color: #000000">Erstrangtherapien</span>
+Bei einer Resistent gegenüber Metronidazol von rund 40% in Deutschland, verbietet sich eine Eradikationstherapie, welche Metronidazol enthält (Ausnahme die Bismuth-Quadrupeltherapie)
+Die Resistenzlage gegenüber Clarithromycin ist in Deutschland ebenfalls problematisch und beträgt aktuell rund 20%.
+Folgendes Vorgehen wird empfohlen:
+# Erstlinientherapie mit der Bismuth-Quadrupeltherapie, falls eine Clarithromycin Resistenz anzunehmen ist.
+# Falls eine Clarithromycin Resistenz unwahrscheinlich ist, wird die Französische Tripeltherapie empfohlen
+# Falls die Eradikation nicht erfolgreich war, dann Zweitlinientherapie mit der Bismuth-Quadrupeltherapie oder mit der Fluorochinolon-Tripeltherapie
+# Falls die Eradikation erneut nicht erfolgreich sein sollte dann Resistenztestung und entsprechende Therapie
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cellspacing="0" border="0" cellpadding="0" style="margin-left:0pt;mso-padding-alt:0pt 5.3858267716535435pt 0pt 5.3858267716535435pt;border-left:0.5pt solid #000000;border-top:0.5pt solid #000000;border-right:0.5pt solid #000000;border-bottom:0.5pt solid #000000;mso-border-insidev:0.5pt solid #000000;mso-border-insideh:0.5pt solid #000000;"
+| style="width:120.45000000000002pt;" width="161" |<span style="color: #000000">Erstlininientherapien</span>
 | style="width:276.4pt;" width="369" |
 | style="width:70.90000000000003pt;" width="95" |<span style="color: #000000">Dauer</span>
 |-
-| style="width:120.45000000000002pt;" width="161" |<span style="color: #000000">Bismuth-Qudrupeltherapie</span>
+| style="width:120.45000000000002pt;" width="161" |<span style="color: #000000">Bismuth-Quadrupeltherapie</span>
 | style="width:276.4pt;" width="369" |<span style="color: #000000">PPI 2 x tgl. 1 Standarddosis</span>
@@ Line 47: / Line 57: @@
 <span style="color: #000000">Clarithromycin 2 x 500 mg</span>
-| style="width:70.90000000000003pt;" width="95" |<span style="color: #000000">10-14 Tage</span>
+| style="width:70.90000000000003pt;" width="95" |<span style="color: #000000">14 Tage</span>
-|-
-| style="width:120.45000000000002pt;" width="161" |<span style="color: #000000">Italienische Tripeltherapie</span>
-| style="width:276.4pt;" width="369" |<span style="color: #000000">PPI 2 x tgl. 1 Standarddosis</span>
-<span style="color: #000000">Metronidazol 2 x 400 mg</span>
-<span style="color: #000000">Clarithromycin 2 x 500 mg</span>
-| style="width:70.90000000000003pt;" width="95" |<span style="color: #000000">10-14 Tage</span>
-|-
-| style="width:120.45000000000002pt;" width="161" |<span style="color: #000000">Komkomittierende Vierfachtherapie</span>
-<span style="color: #000000">Sollten wir evtl. nicht hineinnehmen - M. Oette</span>
-| style="width:276.4pt;" width="369" |<span style="color: #000000">PPI 2 x tgl. 1 Standarddosis</span>
-<span style="color: #000000">Amoxicillin 2 x 1000 mg</span>
-<span style="color: #000000">Clarithromycin 2 x 500 mg</span>
-<span style="color: #000000">Metronidazol 2 x 400 mg</span>
-| style="width:70.90000000000003pt;" width="95" |<span style="color: #000000">10-14 Tage</span>
 |-
-| style="width:120.45000000000002pt;" width="161" |
+| style="width:120.45000000000002pt;" width="161" |<span style="color: #000000">Alternative Zweitlinientherpapie</span>
-| style="width:276.4pt;" width="369" |
-| style="width:70.90000000000003pt;" width="95" |
-|-
-| style="width:120.45000000000002pt;" width="161" |<span style="color: #000000">Alternative Schemata</span>
 | style="width:276.4pt;" width="369" |
 | style="width:70.90000000000003pt;" width="95" |
@@ Line 82: / Line 68: @@
 <span style="color: #000000">Levofloxacin 500 mg oder Moxifloxacin 400 mg 1 x tgl.</span>
-<span style="color: #000000">Amoxicillin 2-3 x 1000 mg</span>
+<span style="color: #000000">Amoxicillin 2 x 1000 mg</span>
 | style="width:70.90000000000003pt;" width="95" |<span style="color: #000000">10-14 Tage</span>
+|-
+|Drittlinientherapie
+|Nach Resistenzbestimmung
+|
 |- style="height:12.65ptpx;"
-| style="width:120.45000000000002pt;" width="161" |<span style="color: #000000">Fluorchinolon-Tripeltherapie II</span>
+| style="width:120.45000000000002pt;" width="161" |Erstlinientherapien
-| style="width:276.4pt;" width="369" |<span style="color: #000000">PPI 2 x tgl. 1 Standarddosis</span>
-<span style="color: #000000">Levofloxacin 500 mg oder Moxifloxacin 400 mg 1 x tgl.</span>
-<span style="color: #000000">Rifabutin 2 x 150 mg</span>
-| style="width:70.90000000000003pt;" width="95" |<span style="color: #000000">10-14 Tage</span>
-|- style="height:12.65ptpx;"
-| style="width:120.45000000000002pt;" width="161" |<span style="color: #000000">Sequenztherapie</span>
-<span style="color: #000000">Sollten wir nicht hineinnehmen - M. Oette</span>
-| style="width:276.4pt;" width="369" |<span style="color: #000000">PPI 2 x tgl. 1 Standarddosis</span>
-<span style="color: #000000">Amoxicillin 2-3 x 1000 mg (Tag 1-5)</span>
-<span style="color: #000000">Clarithromycin 2 x 500 mg (Tage 6-10)</span>
-<span style="color: #000000">Metronidazol 2 x 400 mg (Tage 6-10)</span>
-| style="width:70.90000000000003pt;" width="95" |<span style="color: #000000">10 Tage</span>
-|- style="height:12.65ptpx;"
-| style="width:120.45000000000002pt;" width="161" |
 | style="width:276.4pt;" width="369" |
-| style="width:70.90000000000003pt;" width="95" |
+| style="width:70.90000000000003pt;" width="95" |Dauer
 |- style="height:12.65ptpx;"
 | colspan="2" style="width:396.85pt;" width="529" |<span style="color: #000000">Äquivalenzdosierungen der Protonenpumpenhemmer (PPI)</span>
@@ Line 115: / Line 85: @@
 | style="width:276.4pt;" width="369" |<span style="color: #000000">Omeprazol       20 mg</span>
-<span style="color: #000000">Esomeprazol   20 mg</span>
+<span style="color: #000000">Esomeprazol   20 m</span>
 <span style="color: #000000">Pantoprazol     40 mg</span>
@@ Line 126: / Line 96: @@
-Aufgrund der zunehmenden Resistenzen, v.a. gegenüber Metronidazol, Clarythromycin und Levofloxazin, kommt der Bismuth-Quadrupel-Therapie eine überragende Bedeutung zu. Einschränkungen sind der Preis, die hohe Zahl von Tabletten und die Verträglichkeit. Aus der Perspektive der Antibiotikaresistenz ist dieses Schema jedoch als effektiver im Vergleich zu den anderen Kombinationen einzuschätzen. In neuen Bismuth-haltigen Kombinationen ersetzt das Amoxicillin entweder das Tetracyclin oder das Metronidazol.
+Zusammenfassen aufgrund der zunehmenden Resistenzen, v.a. gegenüber Metronidazol, Clarythromycin und Levofloxazin, kommt der Bismuth-Quadrupel-Therapie eine überragende Bedeutung zu. Einschränkungen sind der Preis, die hohe Zahl von Tabletten und die Verträglichkeit. Aus der Perspektive der Antibiotikaresistenz ist dieses Schema jedoch als effektiver im Vergleich zu den anderen Kombinationen einzuschätzen.
-Bei Patienten aus Osteuropa, dem Mittelmeer-Raum und nach erfolgter Makrolidbehandlung sollte diese Antibiotikagfruppe nicht zum Einsatz kommen. Bei Vorliegen eines Resistenztestbefundes kann die Antibiotikakombination nach dem Ergebnis der Empfindlichkeitsprüfung vorgenommen werden. Dieses Vorgehen sollte bei erfolglosen Eradikationsversuchen in der Vergangenheit gewählt werden.
-Sie darf als Standard nach erfolgloser Erstbehandlung angesehen werden. Eine zusätzliche Probiotikagabe zu einer Eradikationstherapie kann erfolgen, um die Verträglichkeit der Eradikationsbehandlung zu verbessern. dies wird jedoch kontrovers beurteilt.
-Bei komplizierten U. duodeni + bei U. ventriculi muss eine Therapiekontrolle erfolgen.
+Neben der Kontrolle des Eradikationserfolgs ist bei U. ventriculi eine endoskopische Kontrolle wichtig. Durch die Therapie sollte das Ulcus/die Ulcera abheilen. Tun sie dieses nicht, so muss erneut endoskopiert werden inklusiv Biopsieentnahme. Hierbei muss das Vorliegen/die Entwicklung eines Malignoms ausgeschlossen werden.<br />
-<br />