Home' Australian Pharmacist : Australian Pharmacist August 2013 Contents 44 Australian Pharmacist August 2013 I ©Pharmaceutical Society of Australia Ltd.
Continuing Professional Development
COUNSELLING IN PRACTICE
The management of these situations
needs to be dealt with case by case.
Factors to consider may include:
• What are the potential consequences if
the interaction occurred?
• Is it appropriate to temporarily stop the
drug affected by clarithromycin?
• Can additional monitoring be
undertaken to mitigate the risk?
• Is there an effective, but safer
alternative antibiotic to clarithromycin?
What other alternatives are there,
and how do they work?
In patients with penicillin hypersensitivity,
first line treatment usually involves
triple therapy with a combination of
metronidazole (replacing the amoxicillin),
clarithromycin and PPI.
If the initial triple-therapy eradication
regimen is ineffective, alternative
approaches can be considered.
• Triple therapy -- with a PPI and two
different antibiotics to those used in
the initial regimen. Amongst those
agents that have been used in this
setting are levofloxacin, rifabutin,
tetracycline and tinidazole. Some of
these agents are not routinely available
in Australia and have to be obtained
via the special access scheme (SAS).
Consequently, for practical purposes
one of the standard antibiotics
used in the initial course may be
repeated. Examples of combinations
recommended in the Therapeutic
amongst people with a family
member who has a history of PUD.
Re-infection, although not common,
can therefore occur domestically.
H. pylori infection rates are also higher
than the average in some groups in
the Australian population, for example
those of lower socio-economic status,
migrants, the elderly and those living
If patients have concerns regarding
ongoing or recurrent symptoms, they
should be advised to seek medical
attention, as a repeat test to detect
the presence of H. pylori may be
indicated. Proton pump inhibitors and
antibiotics should be stopped two
weeks and four weeks prior to testing
respectively, to reduce the risk of false
Are there any complications
associated with the medicines?
Recent years have seen a number of
concerns emerge regarding PPI use, such
as an association with fracture risk and
hypomagnesaemia.5,6 However these
are associated with long term therapy
and not of concern in the context of the
treatment regimen needed for H. pylori
eradication. Furthermore, by achieving
successful eradication, the likelihood of
patients needing long term PPI therapy
and therefore being at risk of these
complications is actually reduced.
As with any broad-spectrum antibacterial
therapy there is always a small risk of
Clostridium difficile associated diarrhoea
(CDAD). Whilst the risks of this are
expected to be outweighed by the
benefits of therapy for established
H. pylori infection in PUD, patients should
be alert to significant diarrhoea (the onset
of which may be delayed by several
weeks) and seek medical attention if
Where can I get more information?
To help those with PUD better understand
their condition and issues surrounding
H. pylori, there are a number of sources
of reliable information that pharmacists
can usefully signpost patients to. These
• Better Health Channel -- Stomach
Ulcer. At: www.betterhealth.vic.gov.au/
Guidelines include amoxicillin with
levofloxacin or amoxicillin with
rifabutin.3 In some cases the course
length may be extended to 14 days to
try and increase success rates, although
the compliance necessary to deliver
this success may be compromised by
the longer course.
• Quadruple therapy -- involves a PPI plus
colloidal bismuth subcitrate and two
antibiotics, such as tetracycline and
metronidazole; for between seven and
14 days. Again the practicality of this
approach is complicated by the need
to obtain both bismuth subcitrate and
tetracycline via the SAS.
• Sequential therapy -- which involves
a two-part regimen in which a five
day course of PPI plus amoxicillin is
followed by a five day course of PPI
plus clarithromycin and metronidazole
In some cases it may be appropriate to
seek specialist (gastroenterology and/or
infectious diseases) advice in the event
of treatment failure. This advice may
be able to provide information on local
resistance patterns, for example whilst
the rate of resistance to clarithromycin
rates amongst H. pylori in Australia
is quoted as between 5% and 7%,3
there may be pockets of higher level
resistance in some areas that make it an
What can I do to stop the condition
Patients who have a history of peptic
ulcer disease can take a number of
self-help steps to reduce the risk of
recurrence. Amongst these are avoiding
or minimising exposure to risk factors
such as smoking, alcohol intake and the
use of systemic NSAIDs.
Re-infection with H. pylori after successful
eradication therapy can occur, but is
considered to be rare. In most cases
where tests for the pathogen are positive
after previous exposure to eradication
therapy this suggests treatment
failure, due to either drug resistance,
poor compliance or both; rather than
re-infection as such.
The bacteria may be spread from
person to person via the oral-faecal
route. Infection rates are higher
'Infection rates are
people with a family
member who has a
history of PUD.'
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