Cp nht iu tr tit tr H.

pylori 2017

TS. BS. Quch Trng c

Tng Th K Lin Chi Hi Ni soi Tiu Ha Vit Nam
Ph Ch Nhim B Mn Ni Tng Qut, HYD TP. HCM
iu tr tit tr H. pylori 2012
Khuyn co ca Hi Khoa hc Tiu ha Vit Nam
Nguyn tc iu tr tit tr H. pylori

2
Khng sinh

Mc tiu
T l tit tr > 95%
(quan im c 80%)

Khng tit
acid mnh
 HI NGH NG THUN V
CHN ON & IU TR H. PYLORI VIT NAM
TP. HCM 24/06/2012
 Kt qu phc u tay
iu tr tit tr H. pylori Vit Nam
 HI NGH NG THUN V
CHN ON & IU TR H. PYLORI VIT NAM
TP. HCM 24/06/2012

27. Khng dng li khng sinh s dng trong phc iu

tr b tht bi trc , c bit l Clarithromycine (ngoi tr
Amoxicilline) v t l khng th pht rt cao.
ng : 93%
Nn lm
Kt qu phcKt
qu
th phc th 2 trong
2 trong
iu
iu tr tit trtr
H.tit tr
pylori H.Vit Vit Nam
Nam
pylori
 HI NGH NG THUN V
CHN ON & IU TR H. PYLORI VIT NAM
TP. HCM 24/06/2012

26. Phc tit tr Helicobacter pylori ln 2

26A. S dng phc 4 thuc c Bismuth nu trc cha dng
ng : 97%.
Nn lm

26B. S dng phc PPI+A+L nu trc dng phc 4 thuc

c Bismuth tht bi.
ng : 93%.
Nn lm
 HI NGH NG THUN V
CHN ON & IU TR H. PYLORI VIT NAM
TP. HCM 24/06/2012

25. Phc tit tr Helicobacter pylori u tay

25A. Min Trung v Bc:
C th s dng phc PPI + A + C trong 10-14 ngy
ng : 76%.
Nn lm

25B. Min Nam:

Phc PPI + A + C km hiu qu. Nn s dng phc ni tip
hoc phc 4 thuc (c / khng c Bismuth) s dng ng thi.
ng : 83%.
Nn lm
 HI NGH NG THUN V
CHN ON & IU TR H. PYLORI VIT NAM
TP. HCM 24/06/2012

28. Phc iu tr cu vn
Trong trng hp vn tit tr tht bi sau hai ln iu tr, cn
nui cy vi khun v lm khng sinh chn khng sinh
ph hp.
ng : 100%
Nn lm
Tit tr H. pylori: cc quan im cp nht
Tnh hnh khng thuc & Cc Khuyn co - ng thun cp nht
Yu t nh hng n hiu qu tit tr H.pylori
J Clin Gastroenterol 2013; 47(3)
 H. pylori a khang VN
Dng khng thuc N (%) (Tng: 92 BN)

Khng khng 12 (13.0%)

AC 0
CH 5 (5.4%)
LE 0
MZ 23 (25.0%)
CH+LE 5 (5.4%)
CH+ MZ 14 (15.2%)
LE+MZ 18 (19.6%)
CH+LE+MZ 14 (15.2%)
AC+CH+LE+MZ 1 (1.1%)

AC: Amoxicillin, CH: Clarithromycin, LE: Levofloxacin, MZ:

Metronidazole
Phan T.N. et al. IJAA 45 (2015) 244248
 Cc khuyn co v ng thun mi

Kyoto global consensus report on Helicobacter pylori

gastritis- 2015
ASEAN Consensus on H. pylori Management in The
Limited Resource Setting 2015
The Toronto Consensus for the Treatment of Helicobacter
pylori Infection in Adults -2016
Management of Helicobacter pylori infectionthe
Maastricht V/Florence Consensus Report -2016
ACG Clinical Guideline: Treatment of Helicobacter pylori
Infection-2017
 im mi ca cc khuyn co cp nht

Ch nh iu tr :
Maastrich V: thm thiu Vit B12
ACG 2017: khng c TC, c nguyn vng T hay c thnh vin
trong gia nh b UTDD

Chn la phc thuc

Chn la u tay (khng CLA >15% thay v 15-20%)
Bismuth Quadruple Therapy
Khng khuyn co phc ni tip (Maastrich V, Toronto 2016)
Phc 4 thuc c Levofloxacin (Maastrich V)

Thi gian iu tr cho tt c phc

14 ngy (tr khi phc 10 ngy khu vc c hiu qu cao)
 ng thun Maastricht V/Florence -2016

Phc b 3 (PPI-clarithromycin-amox) khng nn dng

tr khi c test nhy cm KS nhng vng c t l
khng clarithromycin hn 15%.
nhng vng khng clarithromycin cao (>15%), khuyn
co dng:
Phc 4 thuc c bismuth hay khng c bismuth,
Phc ng thi (PPI, amoxicillin, clarithromycin v
nitroimidazole)
nhng vng khng c clarithromycin v metronidazole
Phc 4 th c bismuth (BQT) c khuyn co l phc chn
la u tin
 ng thun Maastricht V/Florence -2016

Tht bi vi phc 4 thuc c Bismuth:

Phc 3 hay 4 thuc c fluoroquinolone

Trong trng hp khng quinolone cao, kt hp bismuth vi khng

sinh khc hay rifabutin c th c chn la

Tht bi vi phc 4 thuc khng c Bismuth,

Phc 4 thuc c Bismuth hay

Phc 3 thuc hay 4 thuc c fluoroquinolone

(Phc 4 thuc c levofloxacin: PPI, amoxicillin, Levofloxacin, bismuth)
Liu KS khuyn co: ng thun Toronto 2016

Gastroenterology 2016;151:5169
Liu KS khuyn co: ACG guidelines 2017
 ASEAN Consensus on H. pylori Management
in The Limited Resource Setting 2015

Thi gian iu tr ti u ca phc tit tr?

Trong hu ht trng hp, nn dng phc 14 ngy. Ch dng

phc c thi gian iu tr ngn hn nu c chng minh c hiu
qu tit tr l 95% (theo cng nghin cu) v > 95% (theo
nh iu tr).

Mc chng c: Cao
Mc khuyn co: Mnh
Mc ng thun: 95%
ASEAN Consensus on H. pylori Management
in The Limited Resource Setting 2015
 ASEAN Consensus on H. pylori Management
in The Limited Resource Setting 2015

Phc iu tr theo kinh nghim Thuc, liu, thi gian iu tr

ng thi (4 thuc khng Bismuth) A(1g) + C(0.5g) + Tini(0.5g) / M (0.5g) + PPI, bid 14 days

Ni tip (khng khuyn co bng phc 7 ngy u: A (1g) + PPI bid

4 thuc v hiu qu thp hn)
Lai ghp
4 thuc c Bismuth
4 thuc cha Bismuth mi
(amox thay tetracycline)
7 ngy k : C (0.5g) + Tini (0.5g) / M (0.5g) + PPI bid
7 ngy u: A (1g) + PPI bid
7 ngy k: A(1g) + C(0.5g) + Tini (0,5g) / M (0.5g) (1 g) +
PPI bid
Bismuth 2 vin qid + Tetra (500mg) qid +
M (500mg) / Tini (500) tid + PPI bid _ trong 14 ngy
Bismuth 2 vin bid-qid + M/Tini (500 mg) tid + A (1g) bid +
PPI bid _ trong 14 ngy.

iu tr may o (Tailored therapy) (Da trn xt nghim nhy cm khng sinh)

B 3 A (1 g) + C(500 mg) / Tini (500 mg) / M(500 mg)
(nu H. pylori cn nhy Clari / Metro) + PPI bid _ dng trong 14 ngy
B 3 vi Fluoroquinolone
Fluoroquinolone: (vd Levofloxacin 500 mg) qd + A (1g) bid
(nu H. pylori nhy vi
+ PPI bid dng trong 14 ngy
fluoroquinolones)
 ASEAN Consensus on H. pylori Management
in The Limited Resource Setting 2015

Phc th 2 no nn c chn la theo kinh nghim?

Phc th 2 nn s dng cc KS cha tng dng trc hoc

nhng KS t c kh nng khng thuc nh: amoxicillin, bismuth,
tetracycline.

Mc chng c: Cao
Mc khuyn co: Mnh
Mc ng thun: 76.2%
Nguyn tc iu tr tit tr H. pylori

2
Khng sinh

Mc tiu
T l tit tr > 95%
(quan im c 80%)

Khng tit
acid mnh
S dng hp l PPI
PPI man
 nh hng ca pH d dy
trn s phn hy ca khng sinh
pH 1.2 pH 3 pH 4 pH 6
Degradation half-life (hr)

100

80

60

40

20

0
Amoxicillin Clarithromycin Metronidazole

Kita T et al. Pharm res. 2001;18:615-621

 Aliment Pharmacol Ther 2012

5998 BN
 Phn tch theo loi PPI
E tt hn PPI th h I: OR = 1.32 (1.01 1.73), NNT = 21
R tt hn PPI th h I: OR = 1.21 (1.02 1.42), NNT = 23
E & R: khng khc bit OR = 0.9 (0.7 1.17)

Phn tch theo kiu gen CYP2C19

Tnh chung: CYP2C19 nh hng khng c ngha thng k trn
hiu qu tit tr
Ch c dng gen chuyn ha nhanh (EM): dng PPI th h 2 (E / R)
kt qu tt hn th h I OR = 1.37 (1.02 1.84)
Cc yu t khc quyt nh
thnh cng phc iu tr
 HI NGH NG THUN V
CHN ON & IU TR H. PYLORI VIT NAM
TP. HCM 24/06/2012

23. Khng tun th iu tr l mt trong nhng nguyn nhn

chnh dn n iu tr tit tr tht bi. Dnh thi gian t vn,
gii thch cch s dng thuc v cc tc dng ph c th gp
s gip lm tng t l tun th v t l tit tr thnh cng.
ng : 100%
Nn lm
 Ht thuc l lm tng nguy c tht bi
iu tr tit tr Helicobacter pylori
Suzuki et al. Am J Med 2006

T l tit tr thnh cng thp hn 8.4% (95% CI: 3.313.5%; P < 0.01)
nhm bnh nhn cn tip tc ht thuc l trong liu trnh iu tr
 HI NGH NG THUN V
CHN ON & IU TR H. PYLORI VIT NAM
TP. HCM 24/06/2012

24. Khuyn bnh nhn nn ngng ht thuc l v khng ung

ru bia trong thi gian iu tr tit tr Helicobacter pylori v
lm gim hiu qu iu tr tit tr.
ng : 90%
Nn lm
 ng thun Maastricht V/Florence -2016

Mt s loi probiotics c chng minh gim c tc

dng ph ca phc tit tr H. pylori
(Saccharomyces boulardii, Bacillus clausii)
 KT LUN
tit tr H. pylori hiu qu

Chn la phc khng sinh theo khuyn co

Thi gian iu tr cho tt c phc : 14 ngy
Phc u tay: nn l phc 4 thuc cha Bismuth. Khng
khuyn co phc ni tip.
Lu liu khuyn co
S dng thuc c ch toan hiu qu
Cc yu t b tr:
T vn v hng dn cch s dng thuc & tc dng ph
Ngng ru bia & thuc l trong qu trnh tit tr
Phi hp vi cc probiotics c khuyn co
Cm n!