TRIAGE CATEGORY: Enhanced Primary Care Pathway H. … · Enhanced Primary Care Pathway: H. Pylori February 2016 - Page 3/4 2. Hp treatment regimens (Canadian Association of Gastroenterology

Enhanced Primary Care Pathway: H. Pylori February 2016 - Page 1/4

Name:

DOB:

PHN/ULI:

RHRN:

RefMD: Dr.

RefMDFax:

RefDate:

DateToday: March8,2016CONFIRMATION: ReferralReceived R e f r a c t o r y

H.PYLORITRIAGECATEGORY: EnhancedPrimaryCarePathway

REFERRALSTATUS: CLOSEDDearDr.,Theabove-namedpatientwasreferredtoGI-CATforfurtherassessmentofrefractoryHelicobacterpylori(Hp)infectionofthestomachandrelevantGIsymptoms.Basedonfullreviewofyourreferral,ithasbeendetermined that management of this patient within the Enhanced Primary Care Pathway isappropriate,withoutneedforspecialistconsultationatthistime.ThisclinicalpathwayhasbeendevelopedbytheCalgaryZonePrimaryCareNetworkinpartnershipwiththe Section of Gastroenterology andAlbertaHealth Services. These local guidelines are based on bestavailableclinicalevidence,andarepracticalintheprimarycaresetting.Thispackageincludes:

1. FocusedsummaryofHprelevanttoprimarycare2. Summaryof2016CanadianAssociationofGastroenterologyGuidelines

fortreatmentofHelicobacterpylori3. Reviewofyourpatient’sHptreatmenthistory4. Recommendednext-roundHptreatmentregimen5. Checklistforyourin-clinicfollowupofthispatient

ThisreferralisCLOSED.IfyouwouldliketodiscussthisreferralwithaGastroenterologist,callSpecialistLINK,adedicatedGIphoneconsultationservice,available08:00-17:00weekdaysat403-910-2551ortoll-free1-855-387-3151.If your patient completes the Enhanced Primary Care Pathway and remains symptomatic or ifyourpatient’sstatusorsymptomschange,anewreferralindicating‘completedcarepathway’or‘newinformation’shouldbefaxedtoGICentralAccessandTriageat403-944-6540.Thankyou.

KevinRioux,MDPhDFRCPCMedicalLead,GICentralAccessandTriageSectionofGastroenterology


EnhancedPrimaryCarePathway:HELICOBACTERPYLORI

1.FocusedsummaryofHprelevanttoprimarycare

Epidemiology.TheoverallprevalenceofHp inCanada isabout20-30%,but is considerablyhigher inFirstNations communities and in immigrants fromdeveloping countries in SouthAmerica,Africa, andAsiawhereprevalencecanbe70-90%.Infectionmostcommonlyoccursduringchildhood,likelybyfecal-oralroute.TheprevalenceofantibioticresistantstrainsofHpishighincertainimmigrantpopulations.

Symptoms. Many humans are asymptomatic carriers of Hp, but those who develop significantgastroduodenitis experience dyspepsia, which is post-prandial epigastric pain or bloating, nausea,belching, early satiety,or lossof appetite.Most studies suggest thatHpdoesnotplaya role ingastro-esophageal reflux disease, and patients are understandably disappointed when their GERD does notimproveaftereradicationofco-incidentalHpcolonization.

Complications. About 5-15% of patients with Hpwill develop duodenal or gastric ulcers, but this ishigherinpatientswhochronicallyusenonsteroidalanti-inflammatorydrugsincludinglow-doseaspirin(e.g. for long-termmanagement of arthritis or other pain conditions). Hp increases the risk of gastricadenocarcinomaandMALTlymphomabutoveralltheabsoluteriskofthisisverylow,lessthan1%.

Diagnosis.Theureabreathtest(UBT) is themostcommonlyusednon-invasivetest forHpinCalgary.False positive results are rare, but false negatives may result from recent use of antibiotics orantisecretorydrugs(PPIorH2RA).Patientsshouldbeoffantibioticsforatleast4weeksbeforethetest.CLSsuggestsstoppingPPIs3daysbeforethetest,butpreferablythisshouldbe2weeks,and ideally4weeks,whichmaybedifficultforsomepatientswhobecomesymptomaticoffPPI.TheUBTcostsabout$45andtakesaboutonehourforthepatienttocomplete.Who toTest. (1)PatientswithrelevantupperGIsymptoms,andthose(2)witha first-degreerelativewithgastriccancer,(3)startinglong-termNSAIDs,(4)historyofpepticulcerdiseaseorupperGIbleedespeciallyifcontemplatinguseoflowdoseaspirin.Thereisnoclearevidence-basedguidelineinCanadafortestingasymptomaticindividualsbasedoncountryofbirthoraboriginalstatus.

Treatment. In 2016, the Canadian Association of Gastroenterology made significant changes toguidelinesfortreatingHp.Duetoincreasedantibioticresistance,standardtripletherapyregimensarenolonger part of first-line treatment, being replaced by 14-day quadruple therapies, as detailed below.Although resistance of Hp tometronidazole, clarithromycin, and levofloxacin is increasingly common,amoxicillinandtetracyclineremainquitereliablyactiveagainstHp.EvenantibioticsthatHpisresistanttocanbeapartofsuccessfultherapieswhenusedsynergisticallywithatleasttwootherantibioticsandforlongerduration.Accordingtolocalexperience,gastroscopytotestantibioticsensitivitiesinpatientswithapparentrefractoryHpofferslittlespecificguidanceinchoiceofsubsequenttreatment.

Confirming Eradication. Patients should always be retested forHp at least 4weeks after treatment;retesting too soon risks a falsenegative test.Once eradicated, re-infection isunusual.Transmission toothers is unlikely so it is not routinely recommended to test spouses or children of patientswithHp,unlesstheyhavepertinentsymptoms.

TreatmentFailure.Thismayindicateantibioticresistance,butcertainlyintoleranceornon-adherencetotreatmentregimenmustbeexploredwiththepatient.Recurrencelikelyrepresentsrecrudescenceoftheoriginalinfection,promptingalternativeantibioticregimens.


2.Hptreatmentregimens(CanadianAssociationofGastroenterology2016Guidelines)

Tripletherapy(PPI+clarithromycin+amoxicillinormetronidazole)isnolongerrecommended,as studies of Hp isolates in Canada suggest 25-30% are resistant to metronidazole and 15-20% areresistanttoclarithromycin.Withtheexceptionoftherifabutin-basedregimen,alltreatmentsforHpshouldbe14daysduration.FirstRound

CLAMETQuadfor14days• PPIstandarddoseBID• Clarithromycin500mgBID• Amoxicillin1000mgBID• Metronidazole500mgBID

OR

BMTQuadfor14days• PPIstandarddoseBID• Bismuthsubsalicylate524mgQID• Metronidazole375mgQID• Tetracycline500mgBID

SecondRound

• IfCLAMETQuadwasusedasinitialtreatment,thenuseBMTQuadforsecondround• IfBMTQuadwasusedasinitialtreatment,thenuseCLAMETQuadorconsiderLevo-Amox

ThirdRound

Levo-Amoxfor14days• PPIstandarddoseBID• Amoxicillin1000mgBID• Levofloxacin250mgBID

FourthRound

Rif-Amoxfor10days• PPIstandarddoseBID• Rifabutin150mgBID• Amoxicillin1000mgBID

This should only be considered after failure or intolerance of the above three regimens. Rifabutin has rarely been associated with potentially serious myelotoxicity, that is, low white cell or platelet count. The pros and cons of giving fourth-line therapy should be decided on a case-by-case basis.

Patientinformationsheetsforeachoftheseregimensareattachedbelowandareavailablefromyour PCN website. These one-page information sheets list important additional information aboutspecificHptreatmentregimensincludingsideeffectsandwarnings.Ideallythisshouldbepresentedanddiscussedwithyourpatientduringanin-clinicvisit.The patient should be reminded of the importance of completing the entire treatment exactly asprescribed.Forclarityandconvenience,particularlywiththeQuadtherapies,itmaybehelpfultohavetheprescriptionbubblepackedwhichisfreeoranominalchargeatmostpharmacies.Ifpatientshavehadproblems toleratingantibiotics in thepast,administration of probiotics for theentire duration of Hp treatment may improve tolerability and/or improve eradication rates,althoughthisisabroadgeneralizationandcomesataddedcosttothepatient.Ifyourpatientwishestotry this, evidence supports the use of Lactobacillus species, Sacharomyces boulardi, or multi-speciesformulations.


3.ReviewofpreviouslytriedHptreatment(s)forpatient:

DateUBTpositive TwicedailyPPI+listedantibiotics Duration(days) Correctlyprescribed/dispensed?

Yes No

Yes No

Yes No

Yes No

A=amoxicillin,B=bismuth,C=clarithromycin,L=levofloxacin,M=metronidazole,T=tetracycline,R=rifabutin

4.SuggestedsubsequentHptreatmentforpatient:

14dayPPI+clarithromycin+amoxicillin+metronidazoleCLAMET

14dayPPI+bismuthsubsalicylate+metronidazole+tetracyclineBMT

14dayPPI+amoxicillin+levofloxacinLevo-Amox

10dayPPI+rifabutin+amoxicillinRif-Amox

Attachedisaone-pageinformationsheetforyourpatientaboutthisregimen

5.Checklisttoguideyourin-clinicreviewofthispatientaftertreatmentofHp

o RecheckUBT(offantibiotics≥4weeks;offPPI≥3daysbutpreferably≥2weeks)

o IfUBTremainspositive,useanalternativetreatmentandrecheckUBT.Refertoabovetreatmentguidelines.Ifquestions,pleasecallGISpecialistLinkat403-910-2551ortoll-free1-855-387-3151.

o IfUBTnegativebutpersistentsymptoms,sendinanewreferralwithfulldetailstoGICATre:diagnosticendoscopy.

o IfUBTnegativebutfamilyhistoryofgastriccancerinafirst-degreerelative,sendinanewreferralre:screeningendoscopy

February2016–Page1/1

PATIENTINFORMATIONSHEETCLAMETbasedquadrupletherapyforHelicobacterpyloriinfectionofthestomachTakethefollowing4medicationsfor14days.Forconvenienceandclarityofdosing,askyourpharmacisttobubblepackyourprescription.MedicationandDosageForm Dose Frequency

Protonpumpinhibitor(seebelowforstandarddoses) 1pill 2xdaily

Clarithromycin500mg 1capsules(500mg) 2xdaily

Amoxicillin500mg 2capsules(1000mg) 2xdaily

Metronidazole500mg 1tablet(500mg) 2xdailyTreatmentsuccesswillbesignificantlylowerifthemedicationsarenottakenexactlyasprescribed.

Thecostofthisregimenisapproximately$160ifgenericagentsaredispensed.

Protonpumpinhibitors:Theseareveryeffectiveandspecificblockersofacidproductionin the stomach. Disrupting the acid environment favoured by H. pylori makes it moresusceptibletoantibiotics.TherearesixprotonpumpinhibitorsavailableinCanada,listedbygenericandbrandnamesaswellasstandarddosageform:omeprazole20mg(Losec®),lansoprazole 30mg (Prevacid®), pantoprazole 40mg (Pantoloc®), rabeprazole 20mg(Pariet®),esomeprazole40mg(Nexium®),anddexlansoprazole30mg(Dexilant®).AnyofthesePPIdrugscanbeused,astheyareequallyeffectiveinH.pyloritreatments.Clarithromycin (Biaxin®): This antibiotic is frequently used to treat lung and earinfections, but is also effective againstH.pylori. Themost common side effects are tastedisturbance(10%),loosestools(5%)andnausea(2%).Amoxicillin (generic):Thisdrug iscommonlyused to treat lungandbladder infections,but remainsoneof themost reliableantibioticsagainstH.pylori.Themostcommonsideeffectsareloosestools(7%)andskinrash(2%).Shouldaskinrashdevelopwhileonthismedication, discontinue it immediately and contact your physician. If you have had anadverse reaction to penicillin at any time in the past, you must discuss the nature andseverityofthereactionwithyourdoctortodecideabouttheuseofthismedication.

Metronidazole (Flagyl®): This antibiotic is used to treat a variety of gastrointestinalinfections.Themostcommonsideeffectsarenausea,metallictasteinthemouthandloosestools. Itcan interactwithalcohol toproduce flushing,nausea, lowbloodpressure,heartpalpitations or chest discomfort and, therefore, you must not drink any alcohol whiletakingthisdrug.

Additional important information:TheseandotherantibioticscanleadtodevelopmentofClostridiumdifficilediarrhea,affectthereliabilityofthebirthcontrolpill,orinteractwithwarfarin (Coumadin®). Talk to your prescribing physician or pharmacist about potentialinteractionswithyourspecificmedications.Inwomenwhoarepregnantorbreastfeeding,H. pylori treatment should be deferred. Despite the numerous listed potential adverseeffects,mostpeopletoleratethiscombinationoffourdrugswithouttoomuchdifficulty.


PATIENTINFORMATIONSHEETBMTbasedquadrupletherapyforHelicobacterpyloriinfectionofthestomachTakethefollowing4medicationsfor14days.Forconvenienceandclarityofdosing,askyourpharmacisttobubblepackyourprescription.MedicationandDosageForm Dose Frequency


Bismuthsubsalicylate(Pepto-Bismol®)262mg 2caplets(524mg) 4xdaily

Metronidazole250mg 1½tablets(375mg) 4xdaily

Tetracycline500mg 1capsule(500mg) 4xdailyTreatmentsuccesswillbesignificantlylowerifthemedicationsarenottakenexactlyasprescribed.


Protonpumpinhibitors:Theseareveryeffectiveandspecificblockersofacidproductionin the stomach. Disrupting the acid environment favoured by H. pylori makes it moresusceptibletoantibiotics.TherearesixprotonpumpinhibitorsavailableinCanada,listedbygenericandbrandnamesaswellasstandarddosageform:omeprazole20mg(Losec®),lansoprazole 30mg (Prevacid®), pantoprazole 40mg (Pantoloc®), rabeprazole 20mg(Pariet®),esomeprazole40mg(Nexium®),anddexlansoprazole30mg(Dexilant®).AnyofthesePPIdrugscanbeused,astheyareequallyeffectiveinH.pyloritreatments.Bismuth subsalicylate (Pepto-Bismol®): This is an over-the-counter drug commonlyused to treat indigestion,whichalsohas antibiotic effectsonH.pylori. Pepto-Bismolwillcausedarkcoloringof thestooland/orblackappearanceof the tongue,whichdisappearafterthemedicationisstopped.Nervoussystemsideeffects(i.e.dizzinessandconfusion)havebeenreportedbutarerare.Patientswithkidneyproblemsareathigherriskofthesesideeffectsandshouldconsulttheirphysicianbeforetakingthismedication.Metronidazole (Flagyl®): This antibiotic isused to treat a varietyof gut infections.Themostcommonsideeffectsarenausea,metallic taste inthemouthand loosestools. Itcaninteractwithalcoholtoproduceflushing,nausea,lowbloodpressure,heartpalpitationsorchestdiscomfortand,therefore,youmustnotdrinkanyalcoholwhiletakingthisdrug.Tetracycline (generic): This medication is commonly used to treat lung and skininfections,butalsohasreliableantibioticeffectsonH.pylori.Sideeffectsoccurinlessthan5% of patients and include nausea, vomiting, loose stools, and skin rash. Tetracyclinesensitizestheskintotheharmfuleffectsofultravioletlightand,therefore,youmustavoidprolongedsunexposurewhileonthismedication.Additional important information:TheseandotherantibioticscanleadtodevelopmentofClostridiumdifficilediarrhea,affectthereliabilityofthebirthcontrolpill,orinteractwithwarfarin (Coumadin®). Talk to your prescribing physician or pharmacist about potentialinteractionswithyourspecificmedications.Inwomenwhoarepregnantorbreastfeeding,H. pylori treatment should be deferred. Despite the numerous listed potential adverseeffects,mostpeopletoleratethiscombinationoffourdrugswithouttoomuchdifficulty.


PATIENTINFORMATIONSHEETLevo-AmoxbasedtripletherapyforHelicobacterpyloriinfectionofthestomachTakethefollowing3medicationsfor14days.Forconvenienceandclarityofdosing,askyourpharmacisttobubblepackyourprescription.MedicationandDosageForm Dose Frequency


Levofloxacin250mg 1tablet(250mg) 2xdaily

Amoxicillin500mg 2capsules(1000mg) 2xdailyTreatmentsuccesswillbesignificantlylowerifthemedicationsarenottakenexactlyasprescribed.


Protonpumpinhibitors:Theseareveryeffectiveandspecificblockersofacidproductionin the stomach. Disrupting the acid environment favoured by H. pylori makes it moresusceptibletoantibiotics.TherearesixprotonpumpinhibitorsavailableinCanada,listedbygenericandbrandnamesaswellasstandarddosageform:omeprazole20mg(Losec®),lansoprazole 30mg (Prevacid®), pantoprazole 40mg (Pantoloc®), rabeprazole 20mg(Pariet®),esomeprazole40mg(Nexium®),anddexlansoprazole30mg(Dexilant®).AnyofthesePPIdrugscanbeused,astheyareequallyeffectiveinH.pyloritreatments

Levofloxacin (Levaquin®):Thisantibioticismostcommonlyusedtotreat lung,bladder,sinus,andskininfections,butisalsousedtotreatH.pyloriafterinitialfailedattempts.Itisgenerallywell tolerated.Themostcommonandminorsideeffectsareheadache,nausea,anddiarrhea.Raresideeffectsincludenumbnessortinglinginthehandsorfeetandliverinflammationorjaundice.Additionalcautionshouldbeusedinpatientswithknownliverorkidneyproblemsand inpatientswithheart rhythmproblems.Very rarely,useof thismedication has been associatedwithmuscle tendon rupture. Levofloxacin should not beusedbypatientsknowntobeallergictoantibioticsinthesamedrugclassasciprofloxacin.

Amoxicillin (generic):Thisdrug iscommonlyused to treat lungandbladder infections,but remainsoneof themost reliableantibioticsagainstH.pylori.Themostcommonsideeffectsareloosestools(7%)andskinrash(2%).Shouldaskinrashdevelopwhileonthismedication, discontinue it immediately and contact your physician. If you have had anadverse reaction to penicillin at any time in the past, you must discuss the nature andseverityofthereactionwithyourdoctortodecideabouttheuseofthismedication.

Additional important information:TheseandotherantibioticscanleadtodevelopmentofClostridiumdifficilediarrhea,affectthereliabilityofthebirthcontrolpill,orinteractwithwarfarin (Coumadin®). Talk to your prescribing physician or pharmacist about potentialinteractionswithyourspecificmedications.Inwomenwhoarepregnantorbreastfeeding,H. pylori treatment should be deferred. Despite the numerous listed potential adverseeffects,mostpeopletoleratethiscombinationofthreedrugswithouttoomuchdifficulty.


PATIENTINFORMATIONSHEETRif-AmoxbasedtripletherapyforHelicobacterpyloriinfectionofthestomachTakethefollowing3medicationsfor10days.Forconvenienceandclarityofdosing,askyourpharmacisttobubblepackyourprescription.ThisregimenisreservedforpatientswithH.pyloriinfectionthatpersistsdespitemultiplepreviousattemptsatcurewithdistinctantibioticcombinations.MedicationandDosageForm Dose Frequency


Rifabutin150mg 1tablet(150mg) 2xdaily



Protonpumpinhibitors:Theseareveryeffectiveandspecificblockersofacidproductionin the stomach. Disrupting the acid environment favoured by H. pylori makes it moresusceptibletoantibiotics.TherearesixprotonpumpinhibitorsavailableinCanada,listedbygenericandbrandnamesaswellasstandarddosageform:omeprazole20mg(Losec®),lansoprazole 30mg (Prevacid®), pantoprazole 40mg (Pantoloc®), rabeprazole 20mg(Pariet®),esomeprazole40mg(Nexium®),anddexlansoprazole30mg(Dexilant®).AnyofthesePPIdrugscanbeused,astheyareequallyeffectiveinH.pyloritreatments.Rifabutin (Mycobutin®):This antibiotic isusuallyused to treat tuberculosis,but is alsoveryeffectiveagainstH.pyloridueto lowprevalenceofresistance.Rifabutin isexpensiveandmaytakeafewdaystoobtainbyyourpharmacy.Itcommonlycausesametallictasteand orange-reddiscolouration of the urine.About 30%of patients experienceheadache,nausea,diarrhea,rash,ormuscle/jointpain.Rarebutpotentiallyserioussideeffects(<2%incidence)includeliverinjuryordysfunction,orimpairmentofbonemarrowproductionofblood cells with risk of fever, infection, or bleeding. In most cases, these rare adverseeffects disappear when rifabutin is discontinued, but there a few reports of severe orpersistentliverorbonemarrowinjury.Amoxicillin (generic):Thisdrug iscommonlyused to treat lungandbladder infections,but remainsoneof themost reliableantibioticsagainstH.pylori.Themostcommonsideeffectsareloosestools(7%)andskinrash(2%).Shouldaskinrashdevelopwhileonthismedication, discontinue it immediately and contact your physician. If you have had anadverse reaction to penicillin at any time in the past, you must discuss the nature andseverityofthereactionwithyourdoctortodecideabouttheuseofthismedication.Additional important information:TheseandotherantibioticscanleadtodevelopmentofClostridiumdifficilediarrhea,affectthereliabilityofthebirthcontrolpill,orinteractwithwarfarin (Coumadin®). Talk to your prescribing physician or pharmacist about potentialinteractionswithyourspecificmedications.Inwomenwhoarepregnantorbreastfeeding,H. pylori treatment should be deferred. Despite the numerous listed potential adverseeffects,mostpeopletoleratethiscombinationofthreedrugswithouttoomuchdifficulty.

Gastroenterology CENTRAL ACCESS AND TRIAGE Fax: 403-944-6540

http://www.calgarygi.com

Closed referral: H. Pylori and relevant symptoms February 2016 - Page 1/3

Foothills Medical Centre

Dr.JonMeddingsDean of Medicine

Dr.SubrataGhoshHead Department of Medicine

Dr.MarkSwainChair Division of Gastroenterology

Dr.ChrisAndrewsDr.PaulBeckDr.PaulBelletruttiDr.RonBridgesDr.JoseFerrazDr.MariettaIacucciDr.HumbertoJijonDr.GilKaplanDr.PujaKumarDr.YvetteLeungDr.YasminNasserDr.KerriNovakDr.RemoPanaccioneDr.MaitreyiRamanDr.KevinRiouxDr.CynthiaSeowDr.EldonShafferDr.ChristianTurbideSouth Health Campus

Dr.AlexAspinallDr.MichelleBuresiDr.MichaelCurleyDr.MilliGuptaDr.SaumyaJayakumarDr.MeenaMathivananDr.MichaelStewartPeter Lougheed Centre

Dr.PhilipBlusteinDr.EdwinChengDr.SylvainCoderreDr.ShaneDevlinDr.RobertHilsdenDr.SteveHeitmanDr.TarunMisraDr.RachidMohamedDr.MelanieStapletonIBD Nurse Practitioners

JoanHeatheringtonMarie-LouiseMartin

Name:

DOB:

PHN/ULI:

RHRN:

RefMD: Dr.

RefMDFax:

RefDate:

DateToday: March8,2016IMPORTANTNOTICEClosedGIReferral:HelicobacterpyloriandrelevantGIsymptomsDearDr.,Theabove-namedpatientwasreferredtoGICentralAccessandTriage(CAT)withupperGIsymptomsandapositiveureabreathtest(UBT).YouhavealreadybeguntreatmentforHelicobacterpylori(Hp),whichmayresolvetheissueandobviatetheneedforGIconsultation.Thefollowingisanappropriatecourseofaction:

o RecheckUBT(offantibiotics≥4weeks;offPPI≥3daysbutpreferably≥2weeks)

o IfUBTremainspositive,useanalternativetreatmentandrepeatUBT.Pleaserefertoattachedsummaryof2016Hptreatmentguidelinesandpatientinformationsheetsforeachoftheseregimenstoguideyourin-officediscussionofsubsequenttreatment.Ifquestions,pleasecallGISpecialistLinkat403-910-2551ortoll-free1-855-387-3151.

o IfUBTnegativebutpersistentsymptoms,sendinanewreferralwithfulldetailstoGICATre:diagnosticendoscopy.

o IfUBTnegativebutfamilyhistoryofgastriccancerinafirst-degreerelative,sendinanewreferralre:screeningendoscopy

ThisreferralisCLOSED.Ifyouhaveanyquestionsorconcernsaboutthisclosedreferral,pleasecontactusviafaxat403-944-6540.Thankyou.

KevinRioux,MDPhDFRCPCMedicalLead,CentralAccessandTriageSectionofGastroenterology

February 2016 - Page 2/3

1.FocusedsummaryofHprelevanttoprimarycare

Epidemiology.TheoverallprevalenceofHp inCanada isabout20-30%,but is considerablyhigher inFirstNations communities and in immigrants fromdeveloping countries in SouthAmerica,Africa, andAsiawhereprevalencecanbe70-90%.Infectionmostcommonlyoccursduringchildhood,likelybyfecal-oralroute.TheprevalenceofantibioticresistantstrainsofHpishighincertainimmigrantpopulations.

Symptoms. Many humans are asymptomatic carriers of Hp, but those who develop significantgastroduodenitis experience dyspepsia, which is post-prandial epigastric pain or bloating, nausea,belching, early satiety,or lossof appetite.Most studies suggest thatHpdoesnotplaya role ingastro-esophageal reflux disease, and patients are understandably disappointed when their GERD does notimproveaftereradicationofco-incidentalHpcolonization.

Complications. About 5-15% of patients with Hpwill develop duodenal or gastric ulcers, but this ishigherinpatientswhochronicallyusenonsteroidalanti-inflammatorydrugsincludinglow-doseaspirin(e.g. for long-termmanagement of arthritis or other pain conditions). Hp increases the risk of gastricadenocarcinomaandMALTlymphomabutoveralltheabsoluteriskofthisisverylow,lessthan1%.Diagnosis.Theureabreathtest(UBT) is themostcommonlyusednon-invasivetest forHpinCalgary.False positive results are rare, but false negatives may result from recent use of antibiotics orantisecretorydrugs(PPIorH2RA).Patientsshouldbeoffantibioticsforatleast4weeksbeforethetest.CLSsuggestsstoppingPPIs3daysbeforethetest,butpreferablythisshouldbe2weeks,and ideally4weeks,whichmaybedifficultforsomepatientswhobecomesymptomaticoffPPI.TheUBTcostsabout$45andtakesaboutonehourforthepatienttocomplete.

Who toTest. (1)PatientswithrelevantupperGIsymptoms,andthose(2)witha first-degreerelativewithgastriccancer,(3)startinglong-termNSAIDs,(4)historyofpepticulcerdiseaseorupperGIbleedespeciallyifcontemplatinguseoflowdoseaspirin.Thereisnoclearevidence-basedguidelineinCanadafortestingasymptomaticindividualsbasedoncountryofbirthoraboriginalstatus.

Treatment. In 2016, the Canadian Association of Gastroenterology made significant changes toguidelinesfortreatingHp.Duetoincreasedantibioticresistance,standardtripletherapyregimensarenolonger part of first-line treatment, being replaced by 14-day quadruple therapies, as detailed below.Although resistance of Hp tometronidazole, clarithromycin, and levofloxacin is increasingly common,amoxicillinandtetracyclineremainquitereliablyactiveagainstHp.EvenantibioticsthatHpisresistanttocanbeapartofsuccessfultherapieswhenusedsynergisticallywithatleasttwootherantibioticsandforlongerduration.Accordingtolocalexperience,gastroscopytotestantibioticsensitivitiesinpatientswithapparentrefractoryHpofferslittlespecificguidanceinchoiceofsubsequenttreatment.Confirming Eradication. Patients should always be retested forHp at least 4weeks after treatment;retesting too soon risks a falsenegative test.Once eradicated, re-infection isunusual.Transmission toothers is unlikely so it is not routinely recommended to test spouses or children of patientswithHp,unlesstheyhavepertinentsymptoms.

TreatmentFailure.Thismayindicateantibioticresistance,butcertainlyintoleranceornon-adherencetotreatmentregimenmustbeexploredwiththepatient.Recurrencelikelyrepresentsrecrudescenceoftheoriginalinfection,promptingalternativeantibioticregimens.

February 2016 - Page 3/3

Hptreatmentregimens(CanadianAssociationofGastroenterology2016Guidelines)

Tripletherapy(PPI+clarithromycin+amoxicillinormetronidazole)isnolongerrecommended,as studies of Hp isolates in Canada suggest 25-30% are resistant to metronidazole and 15-20% areresistanttoclarithromycin.WiththeexceptionoftheRifabutin-basedregimen,alltreatmentsforHpshouldbe14daysduration.FirstRound

CLAMETQuadfor14days• PPIstandarddoseBID• Clarithromycin500mgBID• Amoxicillin1000mgBID• Metronidazole500mgBID

OR

BMTQuadfor14days• PPIstandarddoseBID• Bismuthsubsalicylate524mgQID• Metronidazole375mgQID• Tetracycline500mgBID

SecondRound

• IfCLAMETQuadwasusedasinitialtreatment,thenuseBMTQuadforsecondround.• IfBMTQuadwasusedasinitialtreatment,thenuseCLAMETQuadorconsiderLevo-Amox

ThirdRound

Levo-Amoxfor14days• PPIstandarddoseBID• Levofloxacin250mgBID• Amoxicillin1000mgBID

FourthRound

Rif-Amoxfor10days• PPIstandarddoseBID• Rifabutin150mgBID• Amoxicillin1000mgBID

Thisshouldonlybeconsideredafterfailureorintoleranceoftheabovethreeregimens.Rifabutinhasrarelybeenassociatedwithpotentiallyseriousmyelotoxicity,thatis,lowwhitecellorplateletcount.Theprosandconsofgivingfourth-linetherapyshouldbedecidedonacase-by-casebasis.

Patientinformationsheetsforeachoftheseregimensareattachedbelowandareavailablefromyour PCN website. These one-page information sheets list important additional information aboutspecificHptreatmentregimensincludingsideeffectsandwarnings.Ideallythisshouldbepresentedanddiscussedwithyourpatientduringanin-clinicvisit.The patient should be reminded of the importance of completing the entire treatment exactly asprescribed.Forclarityandconvenience,particularlywiththeQuadthreapies,itmaybehelpfultohavetheprescriptionbubblepackedwhichisanominalchargeatmostpharmacies.Ifpatientshavehadproblems toleratingantibiotics in thepast,administration of probiotics for theentire duration of Hp treatment may improve tolerability and/or improve eradication rates,althoughthisisabroadgeneralizationandcomesataddedcosttothepatient.Ifyourpatientwishestotry this, evidence supports the use of Lactobacillus species, Sacharomyces boulardi, or multi-speciesformulations.


PATIENTINFORMATIONSHEETCLAMETbasedquadrupletherapyforHelicobacterpyloriinfectionofthestomachTakethefollowing4medicationsfor14days.Forconvenienceandclarityofdosing,askyourpharmacisttobubblepackyourprescription.MedicationandDosageForm Dose Frequency


Clarithromycin500mg 1capsules(500mg) 2xdaily

Amoxicillin500mg 2capsules(1000mg) 2xdaily

Metronidazole500mg 1tablet(500mg) 2xdailyTreatmentsuccesswillbesignificantlylowerifthemedicationsarenottakenexactlyasprescribed.


Protonpumpinhibitors:Theseareveryeffectiveandspecificblockersofacidproductionin the stomach. Disrupting the acid environment favoured by H. pylori makes it moresusceptibletoantibiotics.TherearesixprotonpumpinhibitorsavailableinCanada,listedbygenericandbrandnamesaswellasstandarddosageform:omeprazole20mg(Losec®),lansoprazole 30mg (Prevacid®), pantoprazole 40mg (Pantoloc®), rabeprazole 20mg(Pariet®),esomeprazole40mg(Nexium®),anddexlansoprazole30mg(Dexilant®).AnyofthesePPIdrugscanbeused,astheyareequallyeffectiveinH.pyloritreatments.Clarithromycin (Biaxin®): This antibiotic is frequently used to treat lung and earinfections, but is also effective againstH.pylori. Themost common side effects are tastedisturbance(10%),loosestools(5%)andnausea(2%).Amoxicillin (generic):Thisdrug iscommonlyused to treat lungandbladder infections,but remainsoneof themost reliableantibioticsagainstH.pylori.Themostcommonsideeffectsareloosestools(7%)andskinrash(2%).Shouldaskinrashdevelopwhileonthismedication, discontinue it immediately and contact your physician. If you have had anadverse reaction to penicillin at any time in the past, you must discuss the nature andseverityofthereactionwithyourdoctortodecideabouttheuseofthismedication.

Metronidazole (Flagyl®): This antibiotic is used to treat a variety of gastrointestinalinfections.Themostcommonsideeffectsarenausea,metallictasteinthemouthandloosestools. Itcan interactwithalcohol toproduce flushing,nausea, lowbloodpressure,heartpalpitations or chest discomfort and, therefore, you must not drink any alcohol whiletakingthisdrug.

Additional important information:TheseandotherantibioticscanleadtodevelopmentofClostridiumdifficilediarrhea,affectthereliabilityofthebirthcontrolpill,orinteractwithwarfarin (Coumadin®). Talk to your prescribing physician or pharmacist about potentialinteractionswithyourspecificmedications.Inwomenwhoarepregnantorbreastfeeding,H. pylori treatment should be deferred. Despite the numerous listed potential adverseeffects,mostpeopletoleratethiscombinationoffourdrugswithouttoomuchdifficulty.


PATIENTINFORMATIONSHEETBMTbasedquadrupletherapyforHelicobacterpyloriinfectionofthestomachTakethefollowing4medicationsfor14days.Forconvenienceandclarityofdosing,askyourpharmacisttobubblepackyourprescription.MedicationandDosageForm Dose Frequency


Bismuthsubsalicylate(Pepto-Bismol®)262mg 2caplets(524mg) 4xdaily

Metronidazole250mg 1½tablets(375mg) 4xdaily

Tetracycline500mg 1capsule(500mg) 4xdailyTreatmentsuccesswillbesignificantlylowerifthemedicationsarenottakenexactlyasprescribed.


Protonpumpinhibitors:Theseareveryeffectiveandspecificblockersofacidproductionin the stomach. Disrupting the acid environment favoured by H. pylori makes it moresusceptibletoantibiotics.TherearesixprotonpumpinhibitorsavailableinCanada,listedbygenericandbrandnamesaswellasstandarddosageform:omeprazole20mg(Losec®),lansoprazole 30mg (Prevacid®), pantoprazole 40mg (Pantoloc®), rabeprazole 20mg(Pariet®),esomeprazole40mg(Nexium®),anddexlansoprazole30mg(Dexilant®).AnyofthesePPIdrugscanbeused,astheyareequallyeffectiveinH.pyloritreatments.Bismuth subsalicylate (Pepto-Bismol®): This is an over-the-counter drug commonlyused to treat indigestion,whichalsohas antibiotic effectsonH.pylori. Pepto-Bismolwillcausedarkcoloringof thestooland/orblackappearanceof the tongue,whichdisappearafterthemedicationisstopped.Nervoussystemsideeffects(i.e.dizzinessandconfusion)havebeenreportedbutarerare.Patientswithkidneyproblemsareathigherriskofthesesideeffectsandshouldconsulttheirphysicianbeforetakingthismedication.Metronidazole (Flagyl®): This antibiotic isused to treat a varietyof gut infections.Themostcommonsideeffectsarenausea,metallic taste inthemouthand loosestools. Itcaninteractwithalcoholtoproduceflushing,nausea,lowbloodpressure,heartpalpitationsorchestdiscomfortand,therefore,youmustnotdrinkanyalcoholwhiletakingthisdrug.Tetracycline (generic): This medication is commonly used to treat lung and skininfections,butalsohasreliableantibioticeffectsonH.pylori.Sideeffectsoccurinlessthan5% of patients and include nausea, vomiting, loose stools, and skin rash. Tetracyclinesensitizestheskintotheharmfuleffectsofultravioletlightand,therefore,youmustavoidprolongedsunexposurewhileonthismedication.Additional important information:TheseandotherantibioticscanleadtodevelopmentofClostridiumdifficilediarrhea,affectthereliabilityofthebirthcontrolpill,orinteractwithwarfarin (Coumadin®). Talk to your prescribing physician or pharmacist about potentialinteractionswithyourspecificmedications.Inwomenwhoarepregnantorbreastfeeding,H. pylori treatment should be deferred. Despite the numerous listed potential adverseeffects,mostpeopletoleratethiscombinationoffourdrugswithouttoomuchdifficulty.


PATIENTINFORMATIONSHEETLevo-AmoxbasedtripletherapyforHelicobacterpyloriinfectionofthestomachTakethefollowing3medicationsfor14days.Forconvenienceandclarityofdosing,askyourpharmacisttobubblepackyourprescription.MedicationandDosageForm Dose Frequency


Levofloxacin250mg 1tablet(250mg) 2xdaily



Protonpumpinhibitors:Theseareveryeffectiveandspecificblockersofacidproductionin the stomach. Disrupting the acid environment favoured by H. pylori makes it moresusceptibletoantibiotics.TherearesixprotonpumpinhibitorsavailableinCanada,listedbygenericandbrandnamesaswellasstandarddosageform:omeprazole20mg(Losec®),lansoprazole 30mg (Prevacid®), pantoprazole 40mg (Pantoloc®), rabeprazole 20mg(Pariet®),esomeprazole40mg(Nexium®),anddexlansoprazole30mg(Dexilant®).AnyofthesePPIdrugscanbeused,astheyareequallyeffectiveinH.pyloritreatments

Levofloxacin (Levaquin®):Thisantibioticismostcommonlyusedtotreat lung,bladder,sinus,andskininfections,butisalsousedtotreatH.pyloriafterinitialfailedattempts.Itisgenerallywell tolerated.Themostcommonandminorsideeffectsareheadache,nausea,anddiarrhea.Raresideeffectsincludenumbnessortinglinginthehandsorfeetandliverinflammationorjaundice.Additionalcautionshouldbeusedinpatientswithknownliverorkidneyproblemsand inpatientswithheart rhythmproblems.Very rarely,useof thismedication has been associatedwithmuscle tendon rupture. Levofloxacin should not beusedbypatientsknowntobeallergictoantibioticsinthesamedrugclassasciprofloxacin.

Amoxicillin (generic):Thisdrug iscommonlyused to treat lungandbladder infections,but remainsoneof themost reliableantibioticsagainstH.pylori.Themostcommonsideeffectsareloosestools(7%)andskinrash(2%).Shouldaskinrashdevelopwhileonthismedication, discontinue it immediately and contact your physician. If you have had anadverse reaction to penicillin at any time in the past, you must discuss the nature andseverityofthereactionwithyourdoctortodecideabouttheuseofthismedication.

Additional important information:TheseandotherantibioticscanleadtodevelopmentofClostridiumdifficilediarrhea,affectthereliabilityofthebirthcontrolpill,orinteractwithwarfarin (Coumadin®). Talk to your prescribing physician or pharmacist about potentialinteractionswithyourspecificmedications.Inwomenwhoarepregnantorbreastfeeding,H. pylori treatment should be deferred. Despite the numerous listed potential adverseeffects,mostpeopletoleratethiscombinationofthreedrugswithouttoomuchdifficulty.


PATIENTINFORMATIONSHEETRif-AmoxbasedtripletherapyforHelicobacterpyloriinfectionofthestomachTakethefollowing3medicationsfor10days.Forconvenienceandclarityofdosing,askyourpharmacisttobubblepackyourprescription.ThisregimenisreservedforpatientswithH.pyloriinfectionthatpersistsdespitemultiplepreviousattemptsatcurewithdistinctantibioticcombinations.MedicationandDosageForm Dose Frequency


Rifabutin150mg 1tablet(150mg) 2xdaily



Protonpumpinhibitors:Theseareveryeffectiveandspecificblockersofacidproductionin the stomach. Disrupting the acid environment favoured by H. pylori makes it moresusceptibletoantibiotics.TherearesixprotonpumpinhibitorsavailableinCanada,listedbygenericandbrandnamesaswellasstandarddosageform:omeprazole20mg(Losec®),lansoprazole 30mg (Prevacid®), pantoprazole 40mg (Pantoloc®), rabeprazole 20mg(Pariet®),esomeprazole40mg(Nexium®),anddexlansoprazole30mg(Dexilant®).AnyofthesePPIdrugscanbeused,astheyareequallyeffectiveinH.pyloritreatments.Rifabutin (Mycobutin®):This antibiotic isusuallyused to treat tuberculosis,but is alsoveryeffectiveagainstH.pyloridueto lowprevalenceofresistance.Rifabutin isexpensiveandmaytakeafewdaystoobtainbyyourpharmacy.Itcommonlycausesametallictasteand orange-reddiscolouration of the urine.About 30%of patients experienceheadache,nausea,diarrhea,rash,ormuscle/jointpain.Rarebutpotentiallyserioussideeffects(<2%incidence)includeliverinjuryordysfunction,orimpairmentofbonemarrowproductionofblood cells with risk of fever, infection, or bleeding. In most cases, these rare adverseeffects disappear when rifabutin is discontinued, but there a few reports of severe orpersistentliverorbonemarrowinjury.Amoxicillin (generic):Thisdrug iscommonlyused to treat lungandbladder infections,but remainsoneof themost reliableantibioticsagainstH.pylori.Themostcommonsideeffectsareloosestools(7%)andskinrash(2%).Shouldaskinrashdevelopwhileonthismedication, discontinue it immediately and contact your physician. If you have had anadverse reaction to penicillin at any time in the past, you must discuss the nature andseverityofthereactionwithyourdoctortodecideabouttheuseofthismedication.Additional important information:TheseandotherantibioticscanleadtodevelopmentofClostridiumdifficilediarrhea,affectthereliabilityofthebirthcontrolpill,orinteractwithwarfarin (Coumadin®). Talk to your prescribing physician or pharmacist about potentialinteractionswithyourspecificmedications.Inwomenwhoarepregnantorbreastfeeding,H. pylori treatment should be deferred. Despite the numerous listed potential adverseeffects,mostpeopletoleratethiscombinationofthreedrugswithouttoomuchdifficulty.

June2015-Page1/5

PatientName: DateofReferral:

DateofBirth: ReferringMD:

CalgaryRHRN: Fax:

PHN/ULI: Today’sDate:

CONFIRMATION: ReferralReceived

DYSPEPSIATRIAGECATEGORY: EnhancedPrimaryCarePathway

REFERRALSTATUS: CLOSEDDearColleague,Theclinicalanddiagnosticinformationyouhaveprovidedfortheabove-namedpatientisconsistentwithdyspepsia. Based on full review of your referral, it has been determined thatmanagement of thispatientwithin the Enhanced Primary Care Pathway is appropriate, without need for specialistconsultationatthistime.ThisclinicalpathwayhasbeendevelopedbytheCalgaryZonePrimaryCareNetworkinpartnershipwiththe Section of Gastroenterology andAlbertaHealth Services. These local guidelines are based on bestavailableclinicalevidence,andarepracticalintheprimarycaresetting.Thispackageincludes:

1. Focusedsummaryofdyspepsiarelevanttoprimarycare2. Checklisttoguideyourin-clinicpatientreview3. Linkstoadditionalresourcesforthisspecificcondition4. Clinicalflowdiagramwithexpandeddetail



EnhancedPrimaryCarePathway:DYSPEPSIA June2015-Page2/5

EnhancedPrimaryCarePathway:DYSPEPSIA

1.Focusedsummaryofdyspepsiarelevanttoprimarycare

Dyspepsia refers to a symptom complex of gastroduodenal origin, characterized by epigastric pain ordiscomfortthatmaybetriggeredbyeatingandmaybeaccompaniedbyasenseofabdominaldistentionor“bloating”andlossofappetite.TheRomeIIIcommitteeonfunctionalGIdisordersdefinesdyspepsiaasoneormoreofthefollowingsymptoms:

• Postprandialfullness(postprandialdistresssyndrome)• Epigastricpainorburning(epigastricpainsyndrome)• Earlysatiety

Othersymptomssuchasbelchingandnauseamayoccur.There is frequentoverlapbetweendyspepsiaandheartburn,which typifiesgastroesophageal reflux (GERD). Irritablebowel syndromealsooverlapswith functionaldyspepsia,where thepredominantsymptomcomplex includesbloatingandreliefafterdefecation. Biliary tract pain should also be considered, the classic symptom description being post-prandial(worsewithfattymeals)deep-seatedrightupperquadrantpainthatbuildsoverseveralhoursandthendissipates.Dyspeptic symptoms in the general population are common: estimates as high as 30% of individualsexperience dyspeptic symptoms, while few seek medical care. Although the causes of dyspepsiaincludeesophagitis,pepticulcerdisease,Helicobacterpylori infection, celiacdisease,andrarelyneoplasia, most patients with dyspepsia have no organic disease, with a normal battery ofinvestigations including endoscopy. The mechanism of this symptom complex is incompletelyunderstood, but likely involves visceral hypersensitivity, alterations in gastric accommodation andemptyingandalteredcentralpainprocessing.2.Checklisttoguideyourin-clinicreviewofthispatientwithdyspepsiasymptoms

o Absenceofredflagfeatures(weightloss,anemia,irondeficiency,dysphagia,vomiting,age>50ywithnewsymptoms)

o Negativeureabreathtest(mustbedoneoffPPI,H2-receptorantagonists,antacidsforminimumof3days,andoffallantibioticsforminimumof4weeks)

o Lifestylemodificationshavebeendiscussedandpatienthasincorporatedtheseintotheirinitialtreatmentplan(smallermeals,avoidanceofidentifiedfoodtriggers,appropriateweightloss,elevationofheadofbed,smokingcessation)

o PatientadherenttotrialofPPI(canstartoncedailythenescalatetotwicedaily,30minutesbeforebreakfastandsupperforminimumof8weeks)


EnhancedPrimaryCarePathway:DYSPEPSIA3.Linkstoadditionalresourcesforphysiciansandpatients

CalgaryGIDivisionhttp://www.calgarygi.com

MyHealth.Alberta.cahttps://myhealth.alberta.ca/health/pages/conditions.aspx?Hwid=tm6322

CanadianDigestiveHealthFoundationhttp://www.cdhf.ca/en/disorders/details/id/20

UpToDate®–BeyondtheBasicsPatientInformation(freelyaccessible)http://www.uptodate.com/contents/upset-stomach-functional-dyspepsia-in-adults-beyond-the-basics?source=search_result&search=dyspepsia+patient+info&selectedTitle=2~1504.Clinicalflowdiagramwithexpandeddetail

This AHS Calgary Zone pathway incorporates the most current evidence-based clinical guidelines fordiagnosisandmanagementofdyspepsia,frombothGastroenterologyandPrimaryCareliterature:

Miwaetal.Evidence-basedclinicalpracticeguidelinesforfunctionaldyspepsia.JGastroenterol.50:125-39,2015

Ansari etal. Initialmanagement of dyspepsia in primary care: an evidence-based approach. Br J GenPract.63:498-9,2013

Diagnosis and treatment of chronic undiagnosed dyspepsia in adults. Toward Optimized Practicehttp://www.topalbertadoctors.org/cpgs/3294128

AmericanSocietyofGastrointestinalEndoscopyStandardsofPracticeCommittee.Theroleofendoscopyindyspepsia.GastrointestEndosc66:1071-5,2007

Thefollowingisabest-practiceclinicalpathwayformanagementofdyspepsiaintheprimarycaremedicalhome,whichincludesaflowdiagramandexpandedexplanationoftreatmentoptions:



FlowDiagram:DYSPEPSIADiagnosisandManagement-ExpandedDetail1. Establishthediagnosisofdyspepsiaasdefinedabovethroughhistoryandphysicalexamination,excludingworrisome

featuresorredflags.Inthepresenceofanyredflags,referraltoGastroenterologyforconsiderationofurgentendoscopicinvestigationisrecommended,eventhoughthepredictivevalueofthesefeaturesissomewhatlimited.

2. Review of the patient’s medication profile should be undertaken to try to identify obvious culprits such as

ASA/NSAIDs/COX-2 inhibitors, steroids, bisphosphonates, calcium channel blockers, antibiotics, iron or magnesiumsupplements.Anyneworrecentlyprescribedmedication,overthecounterorherbal/naturalproductmaybeimplicatedasvirtuallyallmedicationscancauseGIupsetinsomepatients.

3. BaselineInvestigationsaimedatidentifyingconcerningfeaturesorclearetiologies:

• CBCandferritin• Anti-tissuetransglutaminasehas>95%sensitivitytoruleoutceliacdisease• ALT,ALP,GGT,andlipase,aimedatidentifyingahepatobiliaryorpancreaticsourceofpain• Ifpain isconsistentwithbiliarycolicor liverenzymesor lipaseareabnormalor there isapalpableabdominal

mass,obtainatrans-abdominalultrasound.• UpperGIseriesmaybeconsidered,butislowyieldforrelevantfindings,asisendoscopy

4. Test and treatHelicobacterpyloribyureabreath test (UBT).This strategy isbasedonevidence that somedyspeptic

patientsarecolonizedbyH.pyloriandwillhaveunderlyingpepticulcerdiseaseorgastritis.• IftheUBTispositive,recommendstandardtripleeradicationtherapy:amoxicillin1gBID+clarithromycin500mg

BID + any standard dose PPI BID (see below) for 10-14 days; it is less expensive to provide each componentmedication for10-14d thanbranded triple therapypacks for14d.Confirmeradicationby repeatUBT4weeksaftercompletionofantibiotics.

o Ifthepatientispenicillin-allergic,metronidazole500mgBIDcanbesubstitutedo Ifthepatientisclarithromycin-allergic,usesecondlinetherapybelow

• If the patient fails first-line therapy above, second line quadruple eradication therapy is recommended for 10days: any PPI BID plus bismuth subsalicylate 525mg QID (=Pepto-Bismol 2 caplets or 2 tablespoons QID),metronidazole250mgQIDandtetracycline500mgQID.Bubblepackforpatienteaseandadherence.

• Ifthepatientfailssecondlinetherapy(oristetracycline-allergic),uselevofloxacin-basedregimen:anystandarddosePPIBID+amoxicillin1gBID+levofloxacin250mgBID,allfor10days

• Standard doses of PPIs are: omeprazole 20mg, rabeprazole 20mg, lansoprazole 30mg, pantoprazole 40mg,esomeprazole40mg,dexlansoprazole30mg)

• ALWAYSdiscusswithyourpatientthepossibleminororseriousadverseeffectsofantibiotics• Iffailsthirdlinetherapy,thenrefertoGastroenterology.

5. Lifestylemodification.Therearefewstudiestosupportspecificdietaryrecommendations,butatrialofvariousdietary

exclusionsundertheguidanceofanutritionistorregistereddieticianmaybehelpful,includingavoidanceoflactoseandfoodshighinfructose(FODMAPs).

6. Empiricanti-secretorymedicationtrial.IntheabsenceH.pyloriinfectionorcontinuedsymptomsdespitesuccessfulH.

pylori eradication, a trial of standard dose PPI for 4-8 weeks may benefit some patients. PPIs are favoured over H2-receptorantagonists.Initialtherapyshouldbeoncedaily,30minbeforebreakfast.Ifthereisnosignificantsymptomaticimprovement after 4 weeks, step up to BID dosing or switch to another PPI. If symptoms are then controlled, it isadvisabletotitratedowntothelowesteffectivedose.

7. Trialofmotilityagents.Althoughdelayedgastricemptyingcanbedemonstratedin30-80%ofpatientswithdyspepsia,

gastricemptyingstudiesarenotpartofroutine investigationofdyspepsia.Prokineticagents improvegastricemptying,andsomepatientsmayfindclinicalbenefit.Domperidonecanbeusedinescalatingdoses,suggeststartingat5mgTID-AC,upto10mgPOQIDasa2-4weektrial.

Thereareinsufficientdatatorecommendtheroutineuseofbismuth,antacids,simethicone,misoprostol,anti-cholinergics,anti-spasmodics, TCAs, SSRIs, herbal therapies, probiotics or psychological therapies in functional dyspepsia.However,thesetherapiesmaybeofbenefitinsomepatients,andthusatrialwithassessmentofresponsemaybereasonableandisunlikelytocauseharm.

June2015-Page1/5



CalgaryRHRN: Fax:



GERDTRIAGECATEGORY: EnhancedPrimaryCarePathway

REFERRALSTATUS: CLOSEDDearColleague,Theclinicalanddiagnosticinformationyouhaveprovidedfortheabove-namedpatientisconsistentwithgastroesophageal reflux disease. Based on full review of your referral, it has been determined thatmanagementof thispatientwithin theEnhancedPrimaryCarePathway isappropriate,withoutneedforspecialistconsultationatthistime.ThisclinicalpathwayhasbeendevelopedbytheCalgaryZonePrimaryCareNetworkinpartnershipwiththe Section of Gastroenterology andAlbertaHealth Services. These local guidelines are based on bestavailableclinicalevidence,andarepracticalintheprimarycaresetting.Thispackageincludes:

1. FocusedsummaryofGERDrelevanttoprimarycare2. Checklisttoguideyourin-clinicpatientreview3. Linkstoadditionalresourcesforthisspecificcondition4. Clinicalflowdiagramwithexpandeddetail

ThisreferralisCLOSED.IfyouwouldliketodiscussthisreferralwithaGastroenterologist,callSpecialistLINK,adedicatedGIphoneconsultationservice,available08:00-17:00weekdaysat403-910-2551ortoll-free1-855-387-3151.If your patient completes the Enhanced Primary Care Pathway and remains symptomatic or ifyourpatient’sstatusorsymptomschange,anewreferralindicating‘completedcarepathway’or‘newinformation’shouldbefaxedto403-944-6540.Thankyou.

KevinRioux,MDPhDFRCPCMedicalLead,CentralAccessandTriageSectionofGastroenterology

EnhancedPrimaryCarePathway:GERD June2015-Page2/5

EnhancedPrimaryCarePathway:GERD

1.FocusedsummaryofGERDrelevanttoprimarycare

Therefluxofgastriccontentsintotheesophagusisanormalphysiologicalphenomenon.Refluxisdeemedpathologicalwhenitcausesesophagealinjuryorproducessymptomsthataretroublesometothepatient,typicallyheartburnandregurgitation,aconditionknownasgastroesophagealrefluxdisease.GERDisverycommoninprimarycarepracticeandeasytorecognizeinitstypicalform,generallyrequiringnoinitialinvestigations.TreatmentattheprimarycarelevelisfocusedonlifestyleanddietarymodificationstoavoidGERDtriggersandachievehealthybodyweight,andoptimaluseofprotonpumpinhibitor.Ifheartburnisadominantsymptom,thedifferentialdiagnosisincludesvariouscausesofesophagitis(infectious,pill-induced,eosinophilic),pepticulcerdisease,non-ulcerdyspepsia,coronaryarterydisease,biliaryandpancreaticdisease.Insomepatients,GERDhasawiderspectrumofsymptomsincludingchestpain,dysphagia,globussensation,odynophagia,nauseaandwaterbrash.Asrefluxtendstooccuraftereating,thereisoftenoverlapofGERDanddyspepsia,whichreferstopostprandialepigastricdiscomfort.ApresumptivediagnosisofGERDcanbemadeinpatientswithanyoftheclinicalsymptomsdescribedabove,andgenerallynoinvestigationsarerequiredaspartofinitialworkup.ScreeningforH.pyloriisnotrecommendedinGERD.MostpatientswithGERDwillhaveimprovementorresolutionofsymptomswhentreatedwithPPI.Endoscopyiswarrantedinpatientspresentingwithdysphagiaorotheralarmfeatures,andinthoserefractorytoadequateinitialandoptimizedPPItreatments.EsophagealpHorimpedence-pHrefluxmonitoringstudiesaresometimesarrangedbyGIafterendoscopy.GERDcanbecomplicatedbyBarrett’sesophagus,esophagealstrictureand,rarely,esophagealcancer.ScreeningforBarrett’sesophagusisanotherindicationforendoscopy,butspecificcriteriamustbemet:

o ChronicGERD(≥10years)plustwoormoreriskfactors:o >50yearsofageo Malegendero Caucasiano BMI≥30o Waistcircumference>35”forfemalesor>40”formaleso Hiatalhernia(demonstratedradiographically)o FamilyhistoryofesophagealcancerorBarrett’s

o GERDiswellcontrolledwithonceortwicedailyPPI


2.Checklisttoguideyourin-clinicreviewofthispatientwithGERDsymptoms

o SymptomsofGERDwithoutalarmfeatures

o IfdyspepsiaoverlapswithGERD,followEnhancedPrimaryCarePathway:DYSPEPSIA,availableatwww.calgarygi.com

o LifestylefactorsthatcontributetoGERDhavebeenidentifiedanddiscussedwithyourpatient.Ifapplicable,weightlossisessentialtomanagementofGERD,andyourpatientshouldbeguidedandmonitoredtoachievespecificgoals.

o PatientadherenttoinitialtrialofPPIfor8weeks,followedbyreviewandoptimization

3.LinkstoadditionalresourcesforphysiciansandpatientsCalgaryGIDivisionhttp://www.calgarygi.com

WeightManagementMyHealth.Alberta.cahttps://myhealth.alberta.ca/health/pages/conditions.aspx?Hwid=aa122915

WeightWiseAdultCommunityProgramhttp://www.albertahealthservices.ca/services.asp?pid=service&rid=1060802

AlbertaHealthyLivingProgramhttp://www.albertahealthservices.ca/services.asp?pid=service&rid=1005671


UpToDate®–BeyondtheBasicsPatientInformation(freelyaccessible)http://www.uptodate.com/contents/acid-reflux-gastroesophageal-reflux-disease-in-adults-beyond-the-basics?source=search_result&search=GERD+beyond+the+basics&selectedTitle=2~150

4.Clinicalflowdiagramwithexpandeddetail

This AHS Calgary Zone pathway incorporates the most current evidence-based clinical guidelines fordiagnosisandmanagementofGERDfrombothGastroenterologyandPrimaryCareliterature:

Katzetal.Guidelinesforthediagnosisandmanagementofgastroesophagealrefluxdisease.AmJGastroenterol.108:308-28,2013Flooketal.Approachtogastroesophagealrefluxdiseaseinprimarycare:PuttingtheMontrealdefinitionintopractice.CanFamPhysician.54:701-5,2008Kahrilasetal.AmericanGastroenterologicalAssociationInstitutetechnicalreviewonthemanagementofgastroesophagealrefluxdisease.Gastroenterology135:1392-1413,2008.Armstrongetal.Canadianconsensusconferenceonthemanagementofgastroesophagealrefluxdiseaseinadults.CanJGastroenterol.19:15-35,2005TreatmentofGastroesophagealRefluxDiseaseinAdults.TowardOptimizedPracticehttp://www.topalbertadoctors.org/cpgs/3294128

The following is a best-practice clinical pathway formanagement of GERD in the primary caremedicalhome,whichincludesaflowdiagramandexpandedexplanationoftreatmentoptions:



FlowDiagram:GERDDiagnosisandManagement-ExpandedDetail1. ApresumptivediagnosisofGERDcanbemadeinpatientswithtypicalsymptomsofheartburnandregurgitation.

ThepresenceofthesesymptomsisquitespecificforGERD.IfpatientswithsuspectedGERDhavechestpainasadominantfeature, cardiac causes should first be excluded. In the presence of any red flags, referral to Gastroenterology forconsideration of urgent endoscopic investigation is recommended, even though the predictive value of some of thesefeaturesissomewhatlimited.

2. Featuresofdyspepsiashouldbesought.Ifthepatient’sdominantsymptomispostprandialepigastricpainandbloating,pleaserefer to theEnhancedPrimaryCareDYSPEPSIApathway(availableatwww.calgarygi.com).GERDanddyspepsiaclinical pathways are sufficiently distinct and, in particular, the initial assessment of dyspepsia involves testing forH.pyloriandotherlaboratoryinvestigations,whicharenotrequiredinpatientswithGERD.

3. Non-pharmacologicalprinciplesofGERDmanagement.

• Weightlossinpatientswhoareoverweight,orinthosewhohaverecentlygainedweightevenifnormalbodymassindex

• Headofbedelevation(blocksorfoamwedges)andavoidmeals3hbeforebedtimeifnocturnalGERD• Elimination of prototypic GERD triggers (smoking, alcohol, caffeine, carbonated beverages,

spicy/fatty/acidic foods, chocolate andmint) is reasonable, but is not supported by clear evidence ofphysiological or clinical improvement of GERD. Rather than food triggers, it is likely higher yield toprovidedietarycounselingtoGERDpatientstoaffectweightloss.

4. Trialofprotonpumpinhibitor

• AlthoughPPIsare themainstayofGERDtherapy, thereremainsa role forH2RAorantacids (alginates,Ca/Mg/Al salts) inpatientswithmild, infrequent, episodic symptoms.Theseprovide rapidon-demandreliefofheartburnandavoidprematurelycommittingsomepatientstolong-termuseofPPI.

• Forpatientswithmoretroublesomesymptoms,PPIprovidesmoreeffectivelong-termrelief.• An 8-week trial of standard once-daily PPI is recommended (omeprazole 20mg, rabeprazole 20mg,

lansoprazole 30mg, pantoprazole 40mg, esomeprazole 40mg, dexlansoprazole 30mg). There are nomajordifferencesinefficacybetweentheseagents.AllPPIshouldbeadministered30-60minutesbeforebreakfastwiththeexceptionofdexlansoprazole,whichisadualdelayedreleaseformulationthatcanbetakenatanytimeofdayregardlessoffoodintake.

• If symptomsare resolved, PPI shouldbe titrated to lowest effectivemaintenancedose (there arehalf-standarddosesofmostPPIavailablee.g.lansoprazole15mg)orevenattempttodiscontinue,especiallyifweightreductionhasbeenachieved.

• Potential side effects of PPI include headache and diarrhea,whichmay not occurwhen switched to adifferentPPI.There issomeevidencethatPPIuse isassociatedwithC.difficilecolitisandotherentericinfections,andshouldbeusedwithcautionincertainpatientsatrisk.

5. OptimizePPI

• It isestimatedthatone-thirdofpatientswithtypicalGERDwillnotadequatelyrespondtoPPI.FactorsthatpredictPPIfailureareobesityandpooradherencetoPPItreatment.

• Patientnon-adherencetotreatmentwithPPIiscommon.ConfirmthatthepatienthastakentheintendeddoseofPPIonadailybasis,30minutesbeforebreakfastfor8weeks.

• If suboptimal response, switch to another once daily PPI (e.g. esomeprazole) or try high-dose PPI(standarddosePPI twicedaily30minutesbeforebreakfastandsupperordexlansoprazole60mgoncedaily)foranadditional8weeks.Theclinicalandpharmacodynamicdatatosupportthisisactuallyfairlylimited,however.

6. Refractory GERD. Patientswith persistent troublesomeGERD symptoms should be referred to GI Central Access and

Triage for diagnostic evaluation (endoscopy ± pH/impedance reflux monitoring) to discern GERD from non-GERDetiologies.

September2015-Page1/6



CalgaryRHRN: Fax:



IBSTRIAGECATEGORY: EnhancedPrimaryCarePathway

REFERRALSTATUS: CLOSEDDearColleague,Theclinicalanddiagnosticinformationyouhaveprovidedfortheabove-namedpatientisconsistentwithirritable bowel syndrome (IBS). Based on full review of your referral, it has been determined thatmanagementof thispatientwithin theEnhancedPrimaryCarePathway isappropriate,withoutneedforspecialistconsultationatthistime.ThisclinicalpathwayhasbeendevelopedbytheCalgaryZonePrimaryCareNetworkinpartnershipwiththe Section of Gastroenterology andAlbertaHealth Services. These local guidelines are based on bestavailableclinicalevidence,andarepracticalintheprimarycaresetting.Thispackageincludes:

1. FocusedsummaryofIBSrelevanttoprimarycare2. Checklisttoguideyourin-clinicpatientreview3. Linkstoadditionalresourcesforthisspecificcondition4. Clinicalflowdiagramwithexpandeddetail



EnhancedPrimaryCarePathway:IBS September2015-Page2/6

EnhancedPrimaryCarePathway:IBS

1.FocusedsummaryofIBSrelevanttoprimarycare

Irritablebowelsyndromeisacommonsymptomcomplexcharacterizedbychronicabdominalpainandabnormalbowelfunctioninabsenceoforganiccause.ThesekeyfeaturesofIBScanbewidelyvariableinseverityandmayremitandrecur,oftenbeingaffectedbydietaryfactorsandvariousstressors.Reliefof abdominal discomfort after bowel movement is a defining feature. Bowel dysfunction includesfrequent bowel movements, fecal urgency and even incontinence, altered stool form (hard/lumpy orloose/watery),incompleteevacuation,strainingatstool,andpassageofcopiousmucus.IBSisfrequentlyassociatedwithothergastrointestinalsymptomsincludingbloating,flatulence,nausea,burping,earlysatiety,gastroesophagealreflux,anddyspepsia.Extra-intestinalsymptomsalsofrequentlyoccurinIBSpatientsincludingdysuriaandfrequent,urgenturination,widespreadmusculoskeletalpain,dysmenorrhea,dyspareunia,fatigue,anxiety,anddepression.Diagnostic criteria (e.g. Rome or Manning Criteria) for IBS were developed for uniformity of patientrecruitment in clinical trials. In clinical practice, such criteria only provide a framework for assessingpatientswithsuspectedIBS;indeedthesecriteriaalonearefarbetterforrulingoutIBSthanrulingitin.The confident diagnosis of IBS relies on presence of foundational symptoms (i.e. Rome III criteria),recognitionofintestinalandextra-intestinalsymptomsandpsychologicalstressorsthatsupporttheIBSdiagnosis,detailedmedicalhistoryandphysicalexaminationaswellasjudicioususeofinvestigationstoidentifyredflagfeaturesandexcludeorganicconditionsthatmimicIBS.Treatment of IBS involves initial reassurance, dietary, psychological, behavioral interventions,pharmacotherapy based on dominant symptoms, and scheduled patient clinical review, reappraisal,support,andguidance.2.Checklisttoguideyourin-clinicreviewofthispatientwithIBSsymptoms

o RomeIIIcriteriaforIBS:Recurrentabdominalpain≥3dayspermonthinthelastthreemonths,andonsetofpainassociatedwithchangeoffrequencyorformofstool,andpainrelievedbydefecation

o Absenceofredflagfeatures(bleeding,anemia,weightloss,nocturnalorprogressivesymptoms,onsetafterage50)

o Nofamilyhistoryofinflammatoryboweldisease,colorectalcancer,orceliacdisease


EnhancedPrimaryCarePathway:IBS3.Linkstoadditionalresourcesforphysiciansandpatients

CalgaryGIDivisionhttp://www.calgarygi.com

MyHealth.Alberta.cahttps://myhealth.alberta.ca/health/pages/conditions.aspx?Hwid=hw117851


UpToDate®–BeyondtheBasicsPatientInformation(freelyaccessible)http://www.uptodate.com/contents/irritable-bowel-syndrome-beyond-the-basics?source=see_link4.Clinicalflowdiagramwithexpandeddetail

This AHS Calgary Zone pathway incorporates the most current evidence-based clinical guidelines fordiagnosisandmanagementofIBS,frombothGastroenterologyandPrimaryCareliterature:

Weinberg et al. American Gastroenterological Association Institute Guideline on the pharmacologicalmanagementofirritablebowelsyndrome.Gastroenterology147:1146-8,2015.

Wilkinsetal.DiagnosisandmanagementofIBSinadults.AmericanFamilyPhysician86:419-426,2012

Spilleretal.Guidelineson the irritablebowel syndrome:mechanismsandpracticalmanagement.Gut56:1770-98,2007

The following is a best-practice clinical care pathway for management of irritable bowelsyndrome in the primary care medical home, which includes a flow diagram and expandedexplanationoftreatmentoptions:



FlowDiagram:IBSDiagnosisandManagement-ExpandedDetail1. DiagnosisofIBSisbasedonRomeIIIcriteriaofalteredbowelhabitandabdominalpainrelievedby

bowelmovement. IBS requires very little initial laboratory investigation – CBC, ferritin, and celiacdisease screen according to most guidelines. The fecal immunochemical test (FIT) has not beenvalidatedforinvestigationofIBS-likesymptoms;orderingFITinthiscircumstanceis inappropriate.AnemiaorotherredflagfeaturesincreasethelikelihoodoforganicdiseaseandmandatereferraltoGI. Absence of red flags, however, does not completely exclude the possibility of organic disease.Variousother intestinal andextraintestinal featuresoften co-existwith IBSandprovide support tothe diagnosis. It is estimated that unrecognized organic disorderswill be present in about 15%ofpatientswhomeetRomeIIIcriteriaanddonothavealarmfeatures.ThemostcommondiseasesthataremislabeledasIBSareceliacdisease,Crohn’sdisease,andmicroscopiccolitis.IfC-reactiveproteinis≤5mg/L, theprobabilityof IBD is≤1%.GIcancersareveryunlikely inpatients thatmeetusualcriteriaforIBS.Adetailedmedicalhistoryandphysicalexaminationshouldbeperformedatpresentationtoassessfor a multitude of other conditions that mimic IBS. A careful review of medications should beperformed to identify ones that may be causing GI side effects (e.g. PPI, ASA/NSAIDs,laxatives/antacids, iron/calcium/magnesium supplements, calcium channel blockers,antidepressants,opioids,diuretics,herbalproducts).

2. General principles of IBS treatment. All patientswith IBSwill benefit from lifestyle and dietarymodifications,andthismaybeallthatisrequiredinthosewithmildorintermittentsymptomsthatdo not affect quality of life. Key to long-term effective management of IBS is to provide patientreassuranceoftheinitialdiagnosisIBSandofferpointsofreassessmentandreappraisaltoestablishatherapeuticrelationship.Connectingpatientswithresourcesfordiet,exercise,stressreduction,andpsychologicalcounselingisimportant.Screenforandtreatanyunderlyingsleepormooddisorder.

3. Specific approaches based on IBS subtype.Thereare threeclinicalphenotypesof IBS:diarrhea-

predominant(IBS-D),constipation-predominant(IBS-C),andmixedpatternalternatingdiarrheaandconstipation (IBS-M). Categorizing IBS by dominant GI symptom guides focused use of a fewadditionalinvestigations(particularlyinIBS-D),butalsoguidesspecifictreatmentapproaches.UseofpharmaceuticalsinIBSisgenerallyreservedforthosewhohavenotadequatelyrespondedtodietaryandlifestyleinterventions,orinthosewithmoderateorseveresymptomsthatimpairqualityoflife.Pain and bloating is a defining feature of IBS and, in some patients, these features are severe orfrequentenough toaffectqualityof life.Antispasmodicsmaybebeneficial inmanagingorabortingacute episodes of pain, andpatients often take reassurance in having these on-demand treatmentsavailable. For chronic IBS pain, tricyclic antidepressants have shown benefit, andmay have addedbenefitsinthosepatientswithmoodorsleepissues.In absence of alarm features, what would prompt referral for GI consultation and possiblecolonoscopy? Colonoscopy may be helpful in patients with diarrhea predominance who havepersistent symptomsor limitedbenefit fromusual treatments.This ismainly to assess forCrohn’sdiseaseandmicroscopiccolitis. Inpatientswithconstipationpredominanceoralternatingdiarrheaandconstipation,colonoscopyisveryunlikelytoyieldrelevantfindings.


PrinciplesandSpecificsofIBSManagementbySubtype

AllsubtypesofIBS

Exercise Moderatetovigorousexercisefor20-60minutes3-5xperweek

SolubleFibreUseinIBSremainscontroversial,asmaybebeneficialinsomebutdetrimentalinothers.Reasonabletotrypsylliumhuskone-halftoonetablespoondaily.Insolublefibrelikebranisnotbeneficial.

Probiotics Bifidobacteriuminfantis(Align®)1capsule/d($40/mo.)Lactobacillusplantarum229v(TuZen®)1-2capsules/d($40-80/mo.)

Antispasmodics

Peppermintoil(0.2to0.275mLcaps,entericcoated)2capsulesBID($20-25/mo.)HyoscineButylbromide(Buscopan®)10mgTID-QID($25-40/mo.)Dicyclominehydrochloride(Bentylol®)20mgTID-QID($25-40/mo.)PinaveriumBromide(Dicetel®)50-100mgTID($50-75/mo.)Trimebutine(Modulon®)100-200mgTID($40-80/mo.)Allprescribedantispasmodicmedicationsshouldbefullydiscussedwiththepatientintermsofspecificrisksandsideeffectsandappropriatenessofuseincontextoftheirfullmedicalhistory

Antidepressants

Nortriptylineoramitriptyline10-25mgqhs,doseescalateby10-25mg/wkMayrequire25-150mg/d($20-60/mo.);usuallytakes2-3mos.forpeakeffectParticularlyusefulinpatientswithdiarrheaandpainpredominanceorsleepissues/anxiety/depressionUsewithcautioninpatientsatriskofprolongedQT;notesomnolenceandanticholinergicsideeffectsLatestIBStechnicalreviewdoesnotendorseuseofSSRIs

ComplementaryTherapies

PsychologicaltreatmentsMindfulness-basedstressreduction(www.thebreathproject.org)HypnotherapyAccupunctureYoga(www.yogacalgary.ca)

Diarrhea-PredominantIBS

AntidiarrhealsLoperamide(Imodium®)2-4mgBID($25-50/mo.OTC)Cholestyraminepowder(Questran®,Olestyr®)orcolestipol(Colestid®)tablets1-4gpoOD-TIDEspeciallyusefulpost-cholecystectomy.Adviseregardingtimingwithothermedicationstoavoidinteraction;iflongtermuse,riskoffatsolublevitamindeficiencies

FODMAPs CanadianDigestiveHealthFoundationcdhf.ca/bank/document_en/32-fodmaps.pdf

GlutenAvoidance Nonceliacglutensensitivity

Antibiotics Rifaximin(Zaxine®)550mg3x/dailyfor2weekswhichcosts~$325!

Constipation-PredominantIBS

PEG-basedLaxatives Mira-Lax®orLax-a-Day®17-34g/d($25-50/mo.)

Prokinetics Linaclotide(Constella®)145-290µg/d30minutesbeforebreakfast($100-160/mo.)Procalopride(Resotran®)2mg/d,4weektrial($120/mo.)

Documents

TRIAGE CATEGORY: Enhanced Primary Care Pathway H. … · Enhanced Primary Care Pathway: H. Pylori February 2016 - Page 3/4 2. Hp treatment regimens (Canadian Association of Gastroenterology