H. pylori Treatment

Clinical Guidelines: Test, Treat, Test Again

Test: For patients under 60 without alarm symptoms, use stool antigen or urea breath tests. For individuals over 60 or those with alarm symptoms, consider endoscopy. Serology (antibody) testing is not recommended, as it does not detect active infection.

Treat: Initiate treatment upon positive test results. Several treatment regimens are available, taking into account factors such as cost, tolerability, ease of administration, and patient adherence. Provide robust patient education on the importance of completing the entire treatment regimen.

Test Again: Confirm eradication with follow-up testing. This "test-treat-retest" strategy ensures the infection is cured.

Testing Before PPI Prescription

Based on common medical policies, insurance coverage for H. pylori testing and treatment is contingent upon medical necessity, primarily for patients with gastrointestinal symptoms or a history of related diseases. Non-invasive tests, such as urea breath and stool antigen tests, are typically covered, while serology (antibody) testing is not considered medically necessary by most insurers.

Helpful Coding and Billing Guidelines: Helicobacter Pylori Testing

Benefits of Early Testing and Treatment

Decreased complications from untreated, long-term H. pylori infections
Decreased risk for gastric cancer
Reduced risks associated with chronic PPI use
Promoting antibiotic stewardship by appropriately treating patients

H. pylori Fast Facts

Serology tests cannot distinguish active H. pylori from past infection and are not reimbursed by most insurance companies.

Serology's sensitivity and specificity for detecting H. pylori are too poor to recommend it as the initial screening test.

Eradication therapy fails in 1 out of 4 patients due to antibiotic resistance or poor compliance. To improve treatment outcomes and promote effective antibiotic stewardship, ensure that patients are educated on the importance of completing their full course of treatment.

Summary of Treatment Guidelines per the American College of Gastroenterology

First Line Modalities for Treatment-Naive Patients:

Optimized Bismuth Quadruple Therapy (BQT): Includes a 14-day course of a proton pump inhibitor (PPI), bismuth, metronidazole, and tetracycline.
Rifabutin Triple Therapy: PPI, rifabutin, and amoxicillin. Suitable for patients without penicillin allergies.
Potassium-Competitive Acid Blocker (PCAB) Dual Therapy: For patients with penicillin allergies, combine a PCAB such as vonoprazan with amoxicillin.
PCAB-Clarithromycin Triple Therapy: Vonoprazan, clarithromycin, and amoxicillin. Recommended over traditional PPI-clarithromycin triple therapy, especially when clarithromycin susceptibility is unknown.

For Treatment-Experienced Patients:

For patients with persistent H. pylori infection after initial treatment, the guidelines suggest:

Optimized Bismuth Quadruple Therapy: Recommended for patients who have not previously received this regimen.
Rifabutin Triple Therapy: Suggested for patients who have previously undergone BQT.
Levofloxacin Triple Therapy: Considered for patients with known levofloxacin-sensitive strains or when other therapies are unavailable or have been previously used.

*Note: This is a summary; please visit the treatment recommendations page for complete guidelines before making clinical decisions.

ACG Guidelines & Recommendations