Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – Helicobacter pylori testing

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all patients
1st line – 

Helicobacter pylori testing

Because Helicobacter pylori, an infection considered carcinogenic by the World Health Organization, plays a role in the pathogenesis of most cases of atrophic gastritis, it is reasonable to test for the organism and, if present, eradicate it.[39][67]​​

Gastric atrophy in the oxyntic mucosa (fundus and corpus), but not necessarily intestinal metaplasia, may improve when re-examined 10 years after H pylori eradication.[124] However, these findings are controversial.[88][89][125]

Plus – Helicobacter pylori eradication therapy

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ACUTE
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all patients
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with Helicobacter pylori infection
Plus – 

Helicobacter pylori eradication therapy

Treatment recommended for ALL patients in selected patient group

The American College of Gastroenterology (ACG) recommends empirical first-line regimens for treatment-naive patients with H pylori infection.[92]

Optimised bismuth quadruple therapy, consisting of a standard-dose proton-pump inhibitor (PPI) plus bismuth plus tetracycline plus metronidazole for 14 days, is the preferred first-line regimen when antibiotic susceptibility is unknown. This regimen may be used in patients with or without a penicillin allergy.[92]

Other regimens that can be considered first-line for patients with no penicillin allergy include: rifabutin triple therapy (omeprazole plus amoxicillin plus rifabutin) for 14 days; or potassium-competitive acid blocker dual therapy (vonoprazan plus amoxicillin) for 14 days. Potassium-competitive acid blocker triple therapy (vonoprazan plus clarithromycin plus amoxicillin) is another option, but should be avoided in patients with previous exposure to macrolide antibiotics.[92][127]

European guidelines also recommend bismuth quadruple therapy as initial treatment in both areas with clarithromycin resistance rates greater or less than 15%. If this treatment fails, the European guidelines recommend different alternative regimens to the US guidelines. Other options may include levofloxacin triple or quadruple therapy, or clarithromycin triple or quadruple therapy. Choice of the specific regimen depends on the level of clarithromycin resistance and you should consult your local guidelines for options. Fourteen days of treatment are recommended.[91]

All regimens contain antibiotics and therefore may cause diarrhoea, promote opportunistic infections, and interfere with absorption of many other drugs, including oral contraceptives.

Check for eradication of H pylori at least 1 month after the end of therapy with an appropriately conducted urea breath test, fecal antigen test, or biopsy-based test.​[91][92]

To optimise the management of H pylori infection, eradication therapy should be based on patterns of local and individual antimicrobial resistance.[133][134]​ Next-generation sequencing on gastric biopsies to determine antimicrobial susceptibility has been shown to increase the likelihood of successful treatment compared to conventional empirical therapy.[135]​ However, H pylori culture and molecular testing is not widely available in all countries.[136]

Examples of eradication regimens (based on ACG guidelines) are provided here. Specific regimens may be available as proprietary combination formulations. However, local guidelines should be consulted to aid selection of an appropriate regimen and determine treatment courses.

If the first treatment fails, at least one alternative regimen should be tried. Second-line regimens should avoid the antibiotics that were given in the first-line regimen.​[127][132]

In patients who have persistent H pylori infection despite receiving a previous course of eradication therapy, any subsequent treatment is considered second-line (or third-line if they have had two previous courses).[92]​ Choice of regimen will depend on previous treatments. The ACG provides guidance on suggested regimens and it would also be advisable to consult local guidance.[92]

Primary options

Bismuth quadruple therapy

omeprazole: 20 mg orally twice daily

or

lansoprazole: 30 mg orally twice daily

or

rabeprazole: 20 mg orally twice daily

or

esomeprazole: 20 mg orally twice daily

-- AND --

bismuth subsalicylate: 300 mg orally four times daily

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-- AND --

metronidazole: 500 mg orally three to four times daily

-- AND --

tetracycline: 500 mg orally four times daily

OR

Rifabutin triple therapy (treatment-naive)

omeprazole/amoxicillin/rifabutin: (10 mg omeprazole/250 mg amoxicillin/12.5 mg rifabutin per capsule) 4 capsules orally three times daily

OR

Potassium-competitive acid blocker (PCAB) dual therapy

vonoprazan and amoxicillin: 20 mg (vonoprazan) orally twice daily and 1000 mg (amoxicillin) orally three times daily

OR

Potassium-competitive acid blocker (PCAB) triple therapy

vonoprazan and amoxicillin and clarithromycin: 20 mg (vonoprazan) orally twice daily and 1000 mg (amoxicillin) orally twice daily and 500 mg (clarithromycin) orally twice daily

Plus – parenteral vitamin B12

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all patients
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with cobalamin deficiency
Plus – 

parenteral vitamin B12

Treatment recommended for ALL patients in selected patient group

Cobalamin deficiency can be treated with intramuscular cyanocobalamin (vitamin B12).

Primary options

cyanocobalamin: 1000 micrograms intramuscularly once daily or on alternate days for 1 week, followed by 1000 micrograms once weekly for 4-8 weeks, followed by 1000 micrograms once monthly

Plus – iron replacement therapy

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all patients
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with iron deficiency
Plus – 

iron replacement therapy

Treatment recommended for ALL patients in selected patient group

Oral iron is used to treat iron deficiency.

Traditionally, oral ferrous sulfate is prescribed; there is evidence to suggest that once daily or alternate daily dosing regimens may optimise iron absorption and decrease adverse effects compared with standard regimens.[137]

Oral iron is sometimes coformulated with ascorbic acid (vitamin C). Reducing substances such as ascorbic acid promotes the conversion of Fe3+ to Fe2+, thereby improving solubility and absorption.

Parenteral iron can be given intramuscularly but intravenously is the preferred method.[143][144]​ The iron deficit is calculated based on the premise that 1 g of haemoglobin contains 3.3 mg of elemental iron.

Primary options

ferrous sulfate: 65-130 mg orally once daily or on alternate days or three times weekly

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Secondary options

sodium ferric gluconate complex: consult specialist for guidance on dose

OR

iron dextran: consult specialist for guidance on dose

OR

iron sucrose: consult specialist for guidance on dose

OR

ferumoxytol: consult specialist for guidance on dose

OR

ferric carboxymaltose: consult specialist for guidance on dose

Plus – calcium + vitamin D

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ACUTE
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all patients
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with calcium deficiency
Plus – 

calcium + vitamin D

Treatment recommended for ALL patients in selected patient group

There are no specific recommendations regarding prevention or treatment of calcium deficiency in patients with achlorhydria. Based upon recommendations for reducing fracture risk in older people, it would seem reasonable to give the dose used for this indication with a target serum 25-hydroxyvitamin D concentration of >50 nanomol/L (>20 nanograms/mL).

Calcium and vitamin D deficiency may be monitored by periodic serum 25-hydroxyvitamin D as well as bone mineral density testing.[145][146][147]

Primary options

calcium carbonate: 1000-1500 mg orally once daily

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and

ergocalciferol: 800 units orally once daily

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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