Modul: Na izsledkih temelječa medicina. Veljko Ignjatović
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1 Modul: Na izsledkih temelječa medicina Veljko Ignjatović
2 Opis problema: Ambulanto družinske medicine, večkrat na leto obišče gospa srednjih let, po poklicu uslužbenka v banki, zaradi suhega kašlja, hripavosti in občutka pekoče bolečine v zgornjem delu trebuha. Težave so najbolj izrazite po noči. Gastroskopski je ugotovljeno kronično vnetje sluznice želodca, patohistološki pa je potrjeno prisotnost bakterije Helicobacter pylori. Po nasvetu gastroenterologa je bila indicirana trotirna eradikacijska terapija: Zaviralec protonske črpalke 2x40mg + Amoksicilin 2x1000mg + Klaritromicin 2x500mg 7 dni. Po končani predpisani terapiji je bil narejen kontrolni ureaza dihalni test ki je pokazal da je določena kombinacija zdravil ni bila unčikovita.
3 Vprašanje: 1. Ali je smisleno ponovno poskusiti z enakom kombinacijom zdravil in kako dolgo naj bi zdravljenje trajalo? 2. Katera bi bila alternativna terapija v primeru rezistence? Relevantnost problema za delo v ambulanti: Kronični gastritis je široko razširjena bolezen gastrointestinalnega trakta Vzročnik najpogostejše oblike je bakterija Helicobacter pylori
4 10-20% okuženih razvije ulkusno bolezen želodca ali dvanajsternika okužba odgovorna za vsaj 71% do 95% vsih rakov želodca Kronično vnetje gastrične sluznice provzročeno z bakterijo H. Pylori vodi v nastanek multifokalnega atrofičnega gastritisa in intestinalne metaplazije, histoloških sprememb ki veljajo za predhodne spremembe intestinalnega tipa adenokarcinoma želodca in MALT limfoma. SZO zato uvršča bakterijo H. pylori med karcinogene prvega razreda.
5 Pregled relevantnih člankov in virov 1. Tepeš B. Helicobacter pylori diagnostika, zdravljenje in rezistenca na antibiotike v Sloveniji. Revija slovenskega združenja za gastroenterologijo in hepatologijo - Gastroenterolog, Letnik 17, suplement 2, junij Malfertheiner P, Megraud F, O'Morain C, Bazzoli F, El-Omar E, Graham D, Hunt R, Rokkas T, Vakil N, Kuipers EJ. Current concepts in the management of Helicobacter pylori infection: the Maastricht III Consensus Report. Gut Jun;56(6): Epub 2006 Dec 14. PMID: [PubMed - indexed for MEDLINE] 3. Yang JC, Lu CW, Lin CJ. Treatment of Helicobacter pylori infection: current status and future concepts. World J Gastroenterol May 14;20(18): doi: /wjg.v20.i PMID: [PubMed - in process] 4. Graham DY, Shiotani A. New concepts of resistance in the treatment of Helicobacter pylori infections.nat Clin Pract Gastroenterol Hepatol Jun;5(6): doi: /ncpgasthep1138. Epub 2008 Apr 29. Review.PMID: [PubMed - indexed for MEDLINE] 5. Tepes B., O' Connor A., Gisbert J.P., O' Morain C., Treatment of Helicobacter pylori infection Helicobacter September 2012, Volume 17, Supplement 1, ISSN
6 Povzetek virov in osnovnih dilem Po priporočilih Slovenskega združenja za gastrologijo in hepatologijo (SZGH) se okužba s Helicobacter pylori zdravi z zaviralcem protonske črpalke, amoksicilinom/ metronidazolom in klaritromicinom dvakrat dnevno, v trajanju 7 dni. predlagana trotirna shema (ZPČ- klaritromicin - amoksicilin, 2xdnevno, 7 dni, ZAK) z izjemo, da bi se pri bolnikih, ki so bili v življenju večkat zdravljeni z makrolidi, klaritromicin zamenjal z metronidazolom, ZAM. Uspeh klasičnega trotirnega zdravljenja je mogoče izboljšati: Zvišanjem ZPČ 2x40mg in se uspeh izboljša za 6% do 10% Podaljšanje trajanja zdravljenja na 10 dni izboljša uspeh zdravljenja za 4%, podaljšanje na 14 dni pa za 5-6%.
7 Kot terapijo tretjaga izbora ali rescue therapy se svetuje desetodnevno zdravljenje z ZPČ+Amoksicilin+Levofloksacin ali pa zdravljenje po antibiogramu. Zdravljenje druge izbire mora biti desetdnevno. V primeru neuspeha zdravljenja naslednje priporočeno zdravljenje je desetodnevno zdravljenje z ZPČ +Amoksicilinom+Metronidazol+Klaritromicin dvakrat dnevno. Kot terapijo tretjaga izbora ali rescue therapy se svetuje desetodnevno zdravljenje z ZPČ+Amoksicilin+Levofloksacin ali pa zdravljenje po antibiogramu.
8 Priporočilo za prakso na osnovi dokazov in stanja v ambulanti Zdravnik družinske medicine začne zdravljenje z zaviralcem protonske črpalke, amoksicilinom in klaritromicinom dvakrat dnevno, v trajanju 7 dni. Čez mesec dni, če je urea dihalni test ali določanje monoklonalnih protiteles proti Helicobacter pylori v blatu pozitivno, terapija se podaljša na 10 dni z ZPČ, amoksicilinom in metronidazolom dvakrat dnevno. Če je kontrolni test spet pozitiven je smisleno narediti kontrolno gastroskopijo in na podlagi kulture ordinirati antibiotsko terapijo
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