Introduction

Helicobacter pylori (H. pylori) infection remains a major public health problem. Given the high resistance to antibiotics, different treatment strategies must be validated in each specific country. The recurrence rates of H. pylori infection and its predictors remain unclear.

Aims & Methods

To determine the independent factors predicting recurrence after successful eradication with a first-line treatment for H. pylori infection.
All patients were submitted to eradication treatment with five quadruple therapies (A-Concomitant with metronidazole 500mg tid, 14 days; B-Concomitant with metronidazole 500mg bid, 14 days; C-Quadruple with bismuth, 10 days; D-Sequential, 14 days; E-Hybrid, 14 days)) in a blind, randomized trial. Esomeprazole was the proton-pump inhibitor of choice. Efficacy rate at 1-2 months and recurrence rate at 12 months using ¹³C-urea breath test were evaluated. Sociodemographic data, personal/family history, health status and biochemical parameters were assessed using univariate and multivariate analyses.

Results

A total of 126 patients (42.9% males; mean age: 57.4±16.7 years) concluded the treatment protocol (A-25; B-21; C-27; D-24; E-29). Overall efficacy rate of quadruple therapy regimens was 98.4%(n=124): Group A-100%; Group B-100.0%; Group C-100.0%; Group D-100.0%; Group E-93.1% (p=0.147). Overall recurrence rate of quadruple therapy regimens was 4.1%(n=5/123): Group A-12.0%; Group B-9.5%; Group C-0.0%; Group D-0.0%; Group E-0.0% (p=0.009). After univariate/multivariate analysis, high LDL-cholesterol level (OR 1.032, p=0.042), non-bismuth concomitant H. pylori eradication regimen (OR 8.904, p=0.064) and alcoholism (OR 8.333, p=0.035) were independent risk factors for H. pylori reinfection.

Conclusion

In this South-European country, all quadruple therapy regimens with or without bismuth are very effective for H. pylori eradication. The 12-months recurrence rate of H. pylori infection after successful eradication is <5%. High LDL-cholesterol, non-bismuth concomitant H. pylori eradication regimen and alcoholism are independent predictors for H. pylori reinfection. A close surveillance on infectious state in high-risk patients is crucial to prevent long-term H. pylori-associated complications.

References

1. Zamani, M., Ebrahimtabar, F., Zamani, V., et al. (2018) Systematic review with meta-analysis: the worldwide prevalence of Helicobacter pylori infection. Aliment Pharmacol Ther 47(7), 868-876.
2. Malfertheiner, P., Megraud, F., O’Morain, C.A., et al. (2017) Management of Helicobacter pylori infection – the Maastricht V/Florence Consensus Report. Gut 66(1), 6-30.
3. Savoldi, A., Carrara, E., Graham, D.Y., et al. (2018) Prevalence of antibiotic resistance in Helicobacter pylori: a systematic review and meta-analysis in World Health Organization Regions. Gastroenterology 155(5), 1372-1382.
4. Lopo, I., Libânio, D., Pita, I., et al. (2018) Helicobacter pylori antibiotic resistance in Portugal: Systematic review and metaanalysis. Helicobacter 23(4), e12493.
5. Hu, Y., Wan, J.H., Li, X.Y., et al. Systematic review with meta-analysis: the global recurrence rate of Helicobacter pylori. Aliment Pharmacol Ther. 2017;46(9):773-779.
6. Zhao, H., Yan, P., Zhang, N., et al. The recurrence rate of Helicobacter pylori in recent 10 years: A systematic review and meta-analysis. Helicobacter. 2021;26(6):e12852.

Disclosure

None of the authors have anything to declare with regard to personal or financial interests in carrying out this work.

Introduction

Inappropriate proton pump inhibitor (PPI) use is a growing concern, with estimates of up to 70% of long-term use lacking a valid indication (1,2).

Aims & Methods

This study investigates the feasibility of PPI deprescribing in a primary care setting and evaluates its impact on gastrointestinal symptoms and blood values. General practitioners (GPs) recruited long-term, chronic PPI users without strict indication. Demographics, PPI duration/dosage, medical history, and GP-estimated success probability were registered at baseline (Visit 0). Patients on healing-dose PPIs at baseline were down-titrated to maintenance dose for 1 month before deprescription at Visit 1. At Visit 1, all patients were instructed to deprescribe their PPI within one month. After this period, patients returned for Visit 2, where the PPI was stopped completely if feasible. One month later, during Visit 3, patients entered a one-year follow-up period. Patients returned after 6 and 12 months for Visit 4 and 5, respectively, with online questionnaires at 3 and 9 months. Gastrointestinal symptoms (nausea, fullness, bloating, upper abdominal pain, lower abdominal pain, heartburn) were assessed using the PAGI-SYM questionnaire. Successful deprescription was defined as ≤3 PPI doses/month. Optional blood samples at baseline and end of study measured gastrin, magnesium, calcium, iron, and vitamin B12 levels. Results are shown as median(IQR).

Results

Sixty GPs included a total of 640 patients (62(50-70) years, 60% female, BMI 27(25-31) kg/m²). Down-titration from healing to maintenance dose (n=128) before PPI deprescription was successful in 92% of the patients.
One month after deprescribing, 76% of patients (n=444/582) had successfully interrupted their PPI intake. Of these, 78% maintained success, resulting in a sustained success rate of 61% (n=264/432). Success rates did not differ by initial PPI indication (dyspepsia, low-grade GERD, NERD, non-gastric indications), demographics or initial PPI dose. However, GP-estimated success probability at baseline was associated with successful deprescribing at 6 months (p=0.0075, OR = 2.6, 95%CI: 1.3–5.2).
Patients who successfully reduced PPI intake reported a transient increase in heartburn (p<0.0001) after deprescribing (visit1), returning to baseline during follow-up. Interestingly, bloating and postprandial fullness decreased significantly during follow-up (visits 2-4) compared to baseline (both p<0.0001).
A significant difference in delta magnesium (+0.01 vs -0.03 mmol/l, p=0.004) and gastrin levels (-57 vs. -19 pg/mL, p=0.002 ) was observed between successfully (n=105) and unsuccessfully (n=41) deprescribed patients.

Conclusion

PPI deprescription is highly feasible in primary care, with a sustained success rate of 61% after 6 months. While heartburn may transiently increase, bloating and postprandial fullness improved. In patients who successfully reduced PPI intake. Magnesium levels increased while gastrin levels decreased.

References

1. Boghossian TA et al. Deprescribing versus continuation of chronic proton pump inhibitor use in adults. Cochrane Database Syst Rev. 2017 Mar 16;3(3).
2. Heidelbaugh JJ, Kim AH, Walker PC. Overutilization of proton-pump inhibitors: what the clinician needs to know. Therap Adv Gastroenterol. 2012;5(4):219–32.

Disclosure

All authors have declared no conflict of interest.

Introduction

Non-coeliac gluten/wheat sensitivity (NCGWS) is characterized by gastrointestinal and extra-intestinal symptoms triggered by gluten/wheat ingestion in patients without coeliac disease (CD) or wheat allergy. There are controversies on the mechanism leading to this phenomenon, including media influence and the presence of a nocebo effect. Moreover, after the COVID-19 pandemic, a decrease in the rates of NCGWS diagnosis has been noted. The only treatment available for the management of NCGWS is a gluten/wheat-free diet (GFD), yet long-term outcomes are poorly understood. This study aimed to evaluate post-pandemic trends in NCGWS and the long-term GFD adherence in patients with NCGWS. The secondary goals are the assessment of the perceived efficacy of GFD and the need of further medical support.

Aims & Methods

We retrieved data from gluten-free products vendors up to September 2024 (top 6 retailer in the UK) and gluten free products customers up to July 2021, using a questionnaire. Subsequently, patients with self-reported NCGWS referred to a tertiary center clinic from 2006 to 2018 completed a questionnaire regarding their dietary habits and further need of medical advice for symptoms related to their diagnosis. The Biagi score was used to assess their adherence to a GFD. We compared the dietary adherence scores to age and sex matched controls cohort of patients with CD to validate the results.

Results

The marked data analysis showed a persistent rise in the sales of gluten free products, from £200B in 2014 vs £600B in 2024. Moreover, NCGWS patients account for 9.7% of the total number of buyers and for 26% of the spent for GF products.
In our cohort, out of 186 patients with NCGWS, 111 answered the questionnaire (response rate 59.7%, female 82.0%, average age 54 ± 13 years). Of these 111, 58 are not currently following a GFD. Out of the 53/111 patients following a GFD, only 27/53 (50,9%) are adhering strictly (Biagi score 3-4), 2/53 had a Biagi score of 2 (3,8%) indicating poor adherence to a gluten free diet, and 24/53 (45,2%) voluntarily ate gluten (Biagi 1-0). Only two patients report that gluten/wheat is not causing them any symptoms if eaten. The average time patients remained on a gluten free diet was 141±58 months. Compared to patients with CD those with NCGWS on a GFD showed a significantly lower adherence to a GFD (Biagi score of 0-1 NCGS: 73.9% vs CD: 8.1%, p<0.05; Biagi score 3-4, NCGWS: 24.3% vs CD: 90.1%, p<0.05). After being discharged, 40 patients (36.0%) sought medical advice again, but no significant correlation was found between the adherence to a GFD and need for further medical intervention.

Conclusion

Self-reported NCGWS is still consistently present among general population. Unlike CD, the vast majority of patients with self-reported NCGWS do not continue a GFD or significantly reduce their level of adherence. Still, NCGWS patients account for a vast part of the expenses in the gluten-free market. However, over a third of NCGWS sought further medical advice to manage their symptoms. These findings underline the need of a better understanding of this condition and the challenges in the management of these patients.

References

1. Ciacci C, Valitutti F. Where are the non-celiac gluten-sensitive patients gone? The COVID-19 effect. Dig Liver Dis. 2023 May;55(5):690-691. doi: 10.1016/j.dld.2023.02.004. Epub 2023 Mar 3. PMID: 36872202; PMCID: PMC9983782.
2. Barbaro MR, Cremon C, Wrona D, Fuschi D, Marasco G, Stanghellini V, et al. Non-Celiac Gluten Sensitivity in the Context of Functional Gastrointestinal Disorders. Nutrients. 2020 Dec 4;12(12):3735.
3. de Graaf MCG, Lawton CL, Croden F, Smolinska A, Winkens B, Hesselink MAM, et al. The effect of expectancy versus actual gluten intake on gastrointestinal and extra-intestinal symptoms in non-coeliac gluten sensitivity: a randomised, double-blind, placebo-controlled, international, multicentre study. Lancet Gastroenterol Hepatol. 2024 Feb;9(2):110–23.