H. pylori question

[BrightLight]

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A P.A.'s assistant called my pharmacy a few days ago and asked me for recommendation on H. pylori tx. Basically, a patient who was allergic to amoxicillin had failed a trial of regimen that included clarithromycin. Now that tetracycline is nowhere to be found, the assistant asked me for alternatives. As a busy retail pharmacist who could barely keep up with my store's unreachable metrics and with internet speed as fast as snails having orgy while all the useful clinical websites were blocked by the company, I dismissed her with a random answer that I am bit regret now. Out of curiosity, what would you guys recommend in this case?

 

[Notecard]

Pylera + omeprazole maybe? I've never tried to order it though not even sure if you can get it.

 

[rxlea]

What reaction did the patient have to the amoxicillin?

 

[rxlea]

Pylera + omeprazole maybe? I've never tried to order it though not even sure if you can get it.

I agree with this but I know nothing of availability in retail settings

 

[All4MyDaughter]

A P.A.'s assistant called my pharmacy a few days ago and asked me for recommendation on H. pylori tx. Basically, a patient who was allergic to amoxicillin had failed a trial of regimen that included clarithromycin. Now that tetracycline is nowhere to be found, the assistant asked me for alternatives. As a busy retail pharmacist who could barely keep up with my store's unreachable metrics and with internet speed as fast as snails having orgy while all the useful clinical websites were blocked by the company, I dismissed her with a random answer that I am bit regret now. Out of curiosity, what would you guys recommend in this case?

What else was in the regimen with clarithromycin?

 

[Notecard]

What reaction did the patient have to the amoxicillin?

That was my first thought too but I don't think we'll get that info 🙁

 

[BrightLight]

I think they tried clarithro + PPI + metro. Assuming it was a true amoxicillin allergy, I have read that amoxicillin desensitization could be used on patients with no abx alternatives, though I do not know if that is very difficult to perform in real practice. At that time, doxy was what came to my mind, thought now I have a little research it is not as effective as tetracycline. Oh, headaches.

 

[All4MyDaughter]

I agree with this but I know nothing of availability in retail settings

I haven't seen any of the combo packs since I worked in the rich people pharmacy years ago. They are all very expensive and usually not covered by insurance. Most patients can't/won't pay the cash price.

Lexi-comp tells me Helidac is about $700. 😱

 

[Notecard]

I haven't seen any of the combo packs since I worked in the rich people pharmacy years ago. They are all very expensive and usually not covered by insurance. Most patients can't/won't pay the cash price.

Lexi-comp tells me Helidac is about $700. 😱

If they have insurance a PA might cover it with previous failure and an amoxicillin allergy.

 

[All4MyDaughter]

If they have insurance a PA might cover it with previous failure and an amoxicillin allergy.

You are right. My last retail gig was in Medicaid land, so I forget about such things...

 

[rxlea]

I think they tried clarithro + PPI + metro. Assuming it was a true amoxicillin allergy, I have read that amoxicillin desensitization could be used on patients with no abx alternatives, though I do not know if that is very difficult to perform in real practice. At that time, doxy was what came to my mind, thought now I have a little research it is not as effective as tetracycline. Oh, headaches.

Headaches were the allergy?

Well, if the allergy is mild you could always try giving benadryl for the 10-14 day regimen. Itching, mild rash that sort of thing. Hives or anaphylaxis then maybe not. In this patient's case, I would have probably just done PPI + amox + levoflox + diphenhydramine for mild allergy since you really shouldn't be using the same antibiotics used previously. but i have heard of rifabutin + amox + PPI. I think the MOST important thing to talk about when that patient gets to your joint is ADHERENCE.

The resistance to clarithro is pretty significant lately.

 

[Deja]

Headaches were the allergy?

you might want to read his post again

 

[rxlea]

you might want to read his post again

Lulz. I see now. It really took me a while. I was gonna say.....

although, I know someone who says they are allergic to nuts and the reaction is headaches.

My sleep pattern is all screwed up right now. I am sorry if I seem a bit delirious 😛

 

[Lubeckd]

http://www.ncbi.nlm.nih.gov/pubmed/18205669
"esomeprazole, moxifloxacin, and rifabutin for eradication of persistent Helicobacter pylori resistant to both metronidazole and clarithromycin."
How about this regimen?

 

[amox]

omeprazole 20-40mg bid 30min before meals x28
levofloxacin 250mg 1bid wf x14
bismuth subsalicylate 525mg QID x14
High dose probiotic x28