DGI:Helicobacter Pylori/Therapie: Difference between revisions

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#Falls die Eradikation erneut nicht erfolgreich sein sollte dann Resistenztestung und entsprechende Therapie
#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;"
<br />
| style="width:120.45000000000002pt;" width="161" |<span style="color: #000000">Erstlininientherapien</span>
{| class="wikitable"
| style="width:276.4pt;" width="369" |
|+
| style="width:70.90000000000003pt;" width="95" |<span style="color: #000000">Dauer</span>
!Erstlinientherapien
!
!Dauer
|-
|-
| style="width:120.45000000000002pt;" width="161" |<span style="color: #000000">Bismuth-Quadrupeltherapie</span>
|Bismuth-Quadrupeltherapie
| style="width:276.4pt;" width="369" |<span style="color: #000000">PPI 2 x tgl. 1 Standarddosis</span>
|PPI 2 x tgl. 1 Standarddosis


<span style="color: #000000">Bismuth-Kaliumsalz/ Tetracyclin/ Metronidazol</span>
Bismuth-Kaliumsalz/ Tetracyclin/ Metronidazol


<span style="color: #000000">4 x 3 Hartkapseln</span>
4 x 3 Hartkapseln
| style="width:70.90000000000003pt;" width="95" |<span style="color: #000000">10 Tage</span>
|10 Tage
|-
|-
| style="width:120.45000000000002pt;" width="161" |<span style="color: #000000">Französische Tripeltherapie</span>
|Französische Tripeltherapie
| style="width:276.4pt;" width="369" |<span style="color: #000000">PPI 2 x tgl. 1 Standarddosis</span>
|PPI 2 x tgl. 1 Standarddosis


<span style="color: #000000">Amoxicillin 2-3 x 1000 mg</span>
Amoxicillin 2-3 x 1000 mg


<span style="color: #000000">Clarithromycin 2 x 500 mg</span>
Clarithromycin 2 x 500 mg
| style="width:70.90000000000003pt;" width="95" |<span style="color: #000000">14 Tage</span>
|14 Tage
|-
|-
| style="width:120.45000000000002pt;" width="161" |<span style="color: #000000">Alternative Zweitlinientherpapie</span>
|Alternative Zweitlinientherpapie
| style="width:276.4pt;" width="369" |
|
| style="width:70.90000000000003pt;" width="95" |
|
|-
|-
| style="width:120.45000000000002pt;" width="161" |<span style="color: #000000">Fluorchinolon-Tripeltherapie I</span>
|Fluorchinolon-Tripeltherapie I
| style="width:276.4pt;" width="369" |<span style="color: #000000">PPI 2 x tgl. 1 Standarddosis</span>
|PPI 2 x tgl. 1 Standarddosis
 
<span style="color: #000000">Levofloxacin 500 mg oder Moxifloxacin 400 mg 1 x tgl.</span>


<span style="color: #000000">Amoxicillin 2 x 1000 mg</span>
Levofloxacin 500 mg oder Moxifloxacin 400 mg 1 x tgl. Amoxicillin 2 x 1000 mg
| style="width:70.90000000000003pt;" width="95" |<span style="color: #000000">10-14 Tage</span>
|10 - 14 Tage
|-
|-
|Drittlinientherapie
|Drittlinientherapie
|Nach Resistenzbestimmung
|Nach Resistenzbestimmung
|
|
|- style="height:12.65ptpx;"
|-
| style="width:120.45000000000002pt;" width="161" |Erstlinientherapien
|Erstlinientherapien
| style="width:276.4pt;" width="369" |
|
| style="width:70.90000000000003pt;" width="95" |Dauer
|Dauer
|- style="height:12.65ptpx;"
|-
| colspan="2" style="width:396.85pt;" width="529" |<span style="color: #000000">Äquivalenzdosierungen der Protonenpumpenhemmer (PPI)</span>
|Äquivalenzdosierungen der Protonenpumpenhemmer (PPI)
| style="width:70.90000000000003pt;" width="95" |
|
|- style="height:12.65ptpx;"
|
| style="width:120.45000000000002pt;" width="161" |
|-
| style="width:276.4pt;" width="369" |<span style="color: #000000">Omeprazol       20 mg</span>
|
|Omeprazol       20 mg


<span style="color: #000000">Esomeprazol   20 m</span>
Esomeprazol   20 m


<span style="color: #000000">Pantoprazol     40 mg</span>
Pantoprazol     40 mg


<span style="color: #000000">Lansoprazol     30 mg</span>
Lansoprazol     30 mg


<span style="color: #000000">Rabeprazol      20 mg</span>
Rabeprazol      20 mg
| style="width:70.90000000000003pt;" width="95" |
|
|}
|}


Revision as of 13:31, 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:

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


Erstlinientherapien 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


Zusammenfassend 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.

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