paleanne Posted February 27, 2012 Share Posted February 27, 2012 I have ran into several instances over the past month with tetracycline being unavailable at any of our local pharmacies. My current patient is uninsured and has tested postive for H Pylori with symptoms. The cheapest regimine is the tetracycline/metronidazole/BSS/PPI regimine. She cannot afford the others due to the Clarithroymcin cost? Any suggetions?? Doxycycline hasn't been shown to be effective according to a quick search I made.... Link to comment Share on other sites More sharing options...
GeneValgene Posted February 27, 2012 Share Posted February 27, 2012 how about PPI + levofloxacin 500 mg qd + amoxicillin 1gm bid x 7-10 days? still not recommended first line, but i guess if cost is a real factor i guess why not? Should quinolones come first in Helicobacter pylori therapy? Therap Adv Gastroenterol. 2011 Mar;4(2):103-14. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3105620/ Link to comment Share on other sites More sharing options...
deborah212 Posted February 28, 2012 Share Posted February 28, 2012 I would agree with GeneValgene and do PPI+amoxicillin+levofloxacin or just do PPI if symptoms aren't severe until can get tetracycline. It's funny that this question came up because it's in this month's Prescriber's Letter. Here's the reference they used (same authors as above) "A New Look at anti-Helicobacter Pylori Therapy". World J. Gastroenterology. 2011. Sept 21. Copiedbelow from pubmed With the rising prevalence of antimicrobial resistance, the treatment success of standard triple therapy has recently declined to unacceptable levels (i.e., 80% or less) in most countries. Therefore, several treatment regimens have emerged to cure Helicobacter pylori (H. pylori) infection. Novel first-line anti-H. pylori therapies in 2011 include sequential therapy, concomitant quadruple therapy, hybrid (dual-concomitant) therapy and bismuth-containing quadruple therapy. After the failure of standard triple therapy, a bismuth-containing quadruple therapy comprising a proton pump inhibitor (PPI), bismuth, tetracycline and metronidazole can be employed as rescue treatment. Recently, triple therapy combining a PPI, levofloxacin and amoxicillin has been proposed as an alternative to the standard rescue therapy. This salvage regimen can achieve a higher eradication rate than bismuth-containing quadruple therapy in some regions and has less adverse effects. The best second-line therapy for patients who fail to eradicate H. pylori with first-line therapies containing clarithromycin, amoxicillin and metronidazole is unclear. However, a levofloxacin-based triple therapy is an accepted rescue treatment. Most guidelines suggest that patients requiring third-line therapy should be referred to a medical center and treated according to the antibiotic susceptibility test. Nonetheless, an empirical therapy (such as levofloxacin-based or furazolidone-based therapies) can be employed to terminate H. pylori infection if antimicrobial sensitivity data are unavailable. Link to comment Share on other sites More sharing options...
Joelseff Posted February 28, 2012 Share Posted February 28, 2012 Had good response with sequential tx but have 2 recalcitrant cases on long term avelox based therapy...im leaving this practice next month and wont be able to see if its eradicated though... Sent from my myTouch_4G_Slide using Tapatalk Link to comment Share on other sites More sharing options...
paleanne Posted February 28, 2012 Author Share Posted February 28, 2012 Isn't Levofloxacin going to be expensive too? Does anyone know approximate out of pocket cost without insurance? I work in a very poor, rural, underserved community...many of my patients are struggling to even put food on their tables. Link to comment Share on other sites More sharing options...
GeneValgene Posted February 28, 2012 Share Posted February 28, 2012 Isn't Levofloxacin going to be expensive too? Does anyone know approximate out of pocket cost without insurance? I work in a very poor, rural, underserved community...many of my patients are struggling to even put food on their tables. according to my lexicomp this is the generic price: levofloxacin 500mg (50 tabs): $35.99 Link to comment Share on other sites More sharing options...
paleanne Posted February 28, 2012 Author Share Posted February 28, 2012 I just got off the phone with our local pharmacy and levofloxacin here is around 20 bucks generic...so looks like that's what I will go with. Thanks everyone! Link to comment Share on other sites More sharing options...
JHaught Posted May 25, 2012 Share Posted May 25, 2012 I too work in an area where most of my patients pay for their prescriptions. I have run into the problem of a Pt that is allergic to penicillins, cipro, and sulfa, and on Advair which could interact with clarithromycin. I prescribed the PPI+Tetracycline+metronidazole+bismuth. But as you all know Tetracycline is not available. Do any of you have an idea of what combo I could use? Link to comment Share on other sites More sharing options...
Joelseff Posted May 25, 2012 Share Posted May 25, 2012 I too work in an area where most of my patients pay for their prescriptions. I have run into the problem of a Pt that is allergic to penicillins, cipro, and sulfa, and on Advair which could interact with clarithromycin. I prescribed the PPI+Tetracycline+metronidazole+bismuth. But as you all know Tetracycline is not available. Do any of you have an idea of what combo I could use? Does your pt have true allergy to all those abx classes? Makes the choice for an effective tx very difficult. You can try long term flagyl and PPI and pepto for 1 mo. Or refer to GI. At this point your salvaging therapy. How's their asthma? You can assess pts asthma and try to take them off advair to tx the h. Pylori for two weeks, confirm eradication VIA ubt 2-4 weeks after then start them back on advair.... I had great success with sequential therapy when I worked in GI. But with your pts allergy profile thats probably not appropriate. Also consider if pt is symptomatic or are you treating based on positive test? There have been some talk of leaving asymptomatic pts untreated. Check up to date on this if it applies. Good luck! Sent from my myTouch_4G_Slide using Tapatalk Link to comment Share on other sites More sharing options...
JHaught Posted May 25, 2012 Share Posted May 25, 2012 Thank you Joelseff!!! Lots of good ideas. I really appreciate it!! Link to comment Share on other sites More sharing options...
marilynpac Posted May 26, 2012 Share Posted May 26, 2012 I too work in an area where most of my patients pay for their prescriptions. I have run into the problem of a Pt that is allergic to penicillins, cipro, and sulfa, and on Advair which could interact with clarithromycin. I prescribed the PPI+Tetracycline+metronidazole+bismuth. But as you all know Tetracycline is not available. Do any of you have an idea of what combo I could use? If a patient has that many ABX allergies....I would refer to GI... Link to comment Share on other sites More sharing options...
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