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Clinical Trial Details — Status: Recruiting

Administrative data

NCT number NCT05449028
Other study ID # HpETIP
Secondary ID
Status Recruiting
Phase N/A
First received
Last updated
Start date May 1, 2022
Est. completion date December 31, 2024

Study information

Verified date July 2022
Source Centro Hospitalar e Universitário de Coimbra, E.P.E.
Contact Elisa Gravito-Soares, MD
Phone (+351)239400483
Email es18497@gmail.com
Is FDA regulated No
Health authority
Study type Interventional

Clinical Trial Summary

Helicobacter pylori (H. pylori) infection remains a major public health problem, with an estimated prevalence of over 50% worldwide and 60-86% for Portugal. H. pylori is associated with significant morbidity and mortality from peptic ulcerative disease to gastric cancer, whose eradication therapy has proven to be effective in preventing these complications. Factors involved in the development of these conditions include H. pylori virulence, host genetic factors and gut microbiota. Given the increasing pattern of antibiotic resistance evidenced by this bacterium and the scarcity of available antibiotic therapy, both in Portugal and worldwide, there is not enough evidence on the best eradication strategy. Regarding the uncertainties about the potential negative impact of indiscriminate use of eradication therapy on gut microbiota, either by proton pump inhibitors or by antibiotics per se, there is an overriding need for evidence about the real impact of this therapy on oral or gut flora and possible clinical consequences in immunological, metabolic, nutritional and oncological terms. Objectives: Comparative evaluation of the efficacy of the different quadruple therapy regimens recommended for the H. pylori eradication. Comparative evaluation of the safety profile in terms of clinical, and immunological and gut microbiota impact of the different therapies for the H. pylori eradication.


Description:

Introduction: Helicobacter pylori (H. pylori) infection remains a major public health problem, with an estimated prevalence of over 50% worldwide and 60-86% for Portugal. H. pylori is associated with significant morbidity and mortality from peptic ulcerative disease to gastric cancer, whose eradication therapy has proven to be effective in preventing these complications. Factors involved in the development of these conditions include H. pylori virulence, host genetic factors and gut microbiota. Given the increasing pattern of antibiotic resistance evidenced by this bacterium and the scarcity of available antibiotic therapy, both in Portugal and worldwide, there is not enough evidence on the best eradication strategy. Regarding the uncertainties about the potential negative impact of indiscriminate use of eradication therapy on gut microbiota, either by proton pump inhibitors or by antibiotics per se, there is an overriding need for evidence about the real impact of this therapy on oral or gut flora and possible clinical consequences in immunological, metabolic, nutritional and oncological terms. Objectives: Comparative evaluation of the efficacy of the different quadruple therapy regimens recommended for the H. pylori eradication. Comparative evaluation of the safety profile in terms of clinical, and immunological and gut microbiota impact of the different therapies for the H. pylori eradication. Methods: Prospective longitudinal multicentre study of total of patients with gastric infection by H. pylori, diagnosed by 13C-urea breath test or histological analysis of gastric biopsies and clinical indication for its eradication, referred to the different participating Portuguese hospital units and a blind randomized controlled clinical trial of the efficacy and safety of the different quadruple therapy regimes recommended for the H. pylori eradication. This study will be carried out in 4 phases: Phase 1 - Recruitment and randomization of patients by the different quadruple eradication schemes with and without bismuth (5 parallel arms); Phase 2 - H. pylori eradication with evaluation of the efficacy and safety rates at 1 month and the absence of reinfection at 12 months after treatment and collection of stool samples before and after the eradication therapy for evaluation of changes in gut microbiota; Phase 3 - Analysis of richness, diversity and uniformity of gut microbiota by DNA sequencing using the hypervariable region of the ribosomal 16S bacteria gene as a taxonomic identification marker and their clinical impact on immunology, metabolism and nutrition at 12 months after the H. pylori eradication therapy; and Phase 4 - Analysis of immunological changes through the study of cell populations by flow cytometry (CD4+, CD8+, B-cell, T-cell, natural killer cells, cells ratio) and cytokines, chemokines and growth factors by xMAP/Luminex before and 12 months after the H. pylori eradication therapy. Expected results, impact and scientific outputs: Given the high rate of triple therapy inefficacy, high antibiotic resistance and the scarcity and controversy of existing literature on quadruple regimens, there may be relevant differences in the approved quadruple regimens for the H. pylori eradication, being necessary to define which is the most effective and safe in Portugal, decreasing the rate of ineffectiveness and exposure to multiple antibiotics. The homeostasis of gut microbiota is significantly changed after H. pylori eradication and this modification may be substantially different according to the therapeutic scheme used, with clinical implications on immunology, metabolism and nutrition. Thus, a randomized trial to compare quadruple regimens is need, allowing in the future, an individualized selection of the H. pylori eradication regimen, taking into account the higher efficacy and safety and lower gut dysbiosis and its systemic consequences, in short and long term. Modulating oral and gut microbiota therapies, including prebiotics, probiotics, symbiotics, fecal microbiota transplantation and perhaps targeted-immunotherapy may be beneficial as adjuvant therapy to existing H. pylori eradication regimens, in a systematic way or for some therapeutic regimes or risk groups.


Recruitment information / eligibility

Status Recruiting
Enrollment 230
Est. completion date December 31, 2024
Est. primary completion date December 31, 2023
Accepts healthy volunteers No
Gender All
Age group 18 Years and older
Eligibility Inclusion Criteria: - Gastric infection by H. pylori by histological examination of gastric biopsies or carbon 13-labeled urea breath test. Exclusion Criteria: - Age < 18 years; - Pregnant, breast-feeding or women of childbearing age who do not comply with effective anticonception measures; - History of allergy, hypersensitivity or contraindication to the use of H. pylori eradication drugs (antibiotics or proton pump inhibitors); - History of previous gastrointestinal surgery or neoplasia; - Previous H. pylori eradication therapies; Antibiotic or probiotic therapies in the month prior to recruitment; - Use of proton pump inhibitors, other antacids or gastric mucosal protection agents in the 2 weeks prior to recruitment; - Corticosteroids or immunomodulatory therapy in the month prior to recruitment; - Immunodeficiency; - Insulin-treated diabetes mellitus; - Obesity (Body mass index =30Kg/m2); - Use of laxative therapy in the 15 days prior to recruitment; - Decompensated heart, liver, kidney or respiratory diseases and; - Refusal or inability to give informed consent.

Study Design


Related Conditions & MeSH terms


Intervention

Drug:
H. pylori eradication scheme A
Esomeprazole 40mg bid + amoxicillin 1g 12/12h + clarithromycin 500mg 12/12h + metronidazole 500mg 8/8h, for 14 days
H. pylori eradication scheme B
Esomeprazole 40mg bid + amoxicillin 1g 12/12h + clarithromycin 500mg 12/12h + metronidazole 500mg 12/12h, for 14 days
H. pylori eradication scheme C
Esomeprazole 40mg bid + bismuth subsalicylate 420mg 6/6h + metronidazole 375mg 6/6h + tetracycline 375mg 6/6h, for 10 days
H. pylori eradication scheme D
Esomeprazole 40mg bid + amoxicillin 1g 12/12h for 7 days, followed by esomeprazole 40mg bid + clarithromycin 500mg 12/12h + metronidazole 500mg 12/12h for 7 days
H. pylori eradication scheme E
Esomeprazole 40mg bid + amoxicillin 1g 12/12h for 7 days, followed by esomeprazole 40mg bid + amoxicillin 1g 12/12h + clarithromycin 500mg 12/12h + metronidazole 500mg 12/12h for 7 days

Locations

Country Name City State
Portugal Centro Hospitalar e Universitário de Coimbra Coimbra

Sponsors (2)

Lead Sponsor Collaborator
Centro Hospitalar e Universitário de Coimbra, E.P.E. University of Coimbra

Country where clinical trial is conducted

Portugal, 

References & Publications (28)

Almeida N, Donato MM, Romãozinho JM, Luxo C, Cardoso O, Cipriano MA, Marinho C, Fernandes A, Calhau C, Sofia C. Beyond Maastricht IV: are standard empiric triple therapies for Helicobacter pylori still useful in a South-European country? BMC Gastroenterol — View Citation

Almeida N, Romãozinho JM, Donato MM, Luxo C, Cardoso O, Cipriano MA, Marinho C, Fernandes A, Calhau C, Sofia C. Helicobacter pylori antimicrobial resistance rates in the central region of Portugal. Clin Microbiol Infect. 2014 Nov;20(11):1127-33. doi: 10.1 — View Citation

Bagheri N, Salimzadeh L, Shirzad H. The role of T helper 1-cell response in Helicobacter pylori-infection. Microb Pathog. 2018 Oct;123:1-8. doi: 10.1016/j.micpath.2018.06.033. Epub 2018 Jun 21. Review. — View Citation

Boal Carvalho P, Magalhães J, Dias de Castro F, Rosa B, Cotter J. Randomized Controlled Trial for Helicobacter pylori Eradication in a Naive Portuguese Population: Is Sequential Treatment Superior to Triple Therapy in Real World Clinical Setting? Acta Med — View Citation

Buzás GM. Metabolic consequences of Helicobacter pylori infection and eradication. World J Gastroenterol. 2014 May 14;20(18):5226-34. doi: 10.3748/wjg.v20.i18.5226. Review. — View Citation

Carbo A, Bassaganya-Riera J, Pedragosa M, Viladomiu M, Marathe M, Eubank S, Wendelsdorf K, Bisset K, Hoops S, Deng X, Alam M, Kronsteiner B, Mei Y, Hontecillas R. Predictive computational modeling of the mucosal immune responses during Helicobacter pylori — View Citation

Cerqueira RM, Correia M, Vilar H, Manso MC. Cumulative Helicobacter Pylori Eradication Rates by Adopting First- and Second- Line Regimens Proposed by the Maastricht IV Consensus in Obese Patients Undergoing Gastric Bypass Surgery. Obes Surg. 2018 Mar;28(3 — View Citation

Cerqueira RM, Manso MC, Correia MR, Fernandes CD, Vilar H, Nora M, Martins P. Helicobacter pylori eradication therapy in obese patients undergoing gastric bypass surgery--fourteen days superior to seven days? Obes Surg. 2011 Sep;21(9):1377-81. doi: 10.100 — View Citation

Chen L, Xu W, Lee A, He J, Huang B, Zheng W, Su T, Lai S, Long Y, Chu H, Chen Y, Wang L, Wang K, Si J, Chen S. The impact of Helicobacter pylori infection, eradication therapy and probiotic supplementation on gut microenvironment homeostasis: An open-labe — View Citation

Chey WD, Leontiadis GI, Howden CW, Moss SF. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2017 Feb;112(2):212-239. doi: 10.1038/ajg.2016.563. Epub 2017 Jan 10. Erratum in: Am J Gastroenterol. 2018 Jul;113(7):1102. — View Citation

de Boer WA, Thys JC, Borody TJ, Graham DY, O'Morain C, Tytgat GN. Proposal for use of a standard side effect scoring system in studies exploring Helicobacter pylori treatment regimens. Eur J Gastroenterol Hepatol. 1996 Jul;8(7):641-3. — View Citation

Gao JJ, Zhang Y, Gerhard M, Mejias-Luque R, Zhang L, Vieth M, Ma JL, Bajbouj M, Suchanek S, Liu WD, Ulm K, Quante M, Li ZX, Zhou T, Schmid R, Classen M, Li WQ, You WC, Pan KF. Association Between Gut Microbiota and Helicobacter pylori-Related Gastric Lesi — View Citation

Goll R, Cui G, Olsen T, Isaksen V, Gruber F, Husebekk A, Florholmen J. Alterations in antral cytokine gene expression in peptic ulcer patients during ulcer healing and after Helicobacter pylori eradication. Scand J Immunol. 2008 Jan;67(1):57-62. Epub 2007 — View Citation

Graham DY, Lee YC, Wu MS. Rational Helicobacter pylori therapy: evidence-based medicine rather than medicine-based evidence. Clin Gastroenterol Hepatol. 2014 Feb;12(2):177-86.e3; Discussion e12-3. doi: 10.1016/j.cgh.2013.05.028. Epub 2013 Jun 8. — View Citation

Heimesaat MM, Fischer A, Plickert R, Wiedemann T, Loddenkemper C, Göbel UB, Bereswill S, Rieder G. Helicobacter pylori induced gastric immunopathology is associated with distinct microbiota changes in the large intestines of long-term infected Mongolian g — View Citation

Hojo M, Asahara T, Nagahara A, Takeda T, Matsumoto K, Ueyama H, Matsumoto K, Asaoka D, Takahashi T, Nomoto K, Yamashiro Y, Watanabe S. Gut Microbiota Composition Before and After Use of Proton Pump Inhibitors. Dig Dis Sci. 2018 Nov;63(11):2940-2949. doi: — View Citation

Hooi JKY, Lai WY, Ng WK, Suen MMY, Underwood FE, Tanyingoh D, Malfertheiner P, Graham DY, Wong VWS, Wu JCY, Chan FKL, Sung JJY, Kaplan GG, Ng SC. Global Prevalence of Helicobacter pylori Infection: Systematic Review and Meta-Analysis. Gastroenterology. 20 — View Citation

Jafarzadeh A, Larussa T, Nemati M, Jalapour S. T cell subsets play an important role in the determination of the clinical outcome of Helicobacter pylori infection. Microb Pathog. 2018 Mar;116:227-236. doi: 10.1016/j.micpath.2018.01.040. Epub 2018 Jan 31. — View Citation

Jakobsson HE, Jernberg C, Andersson AF, Sjölund-Karlsson M, Jansson JK, Engstrand L. Short-term antibiotic treatment has differing long-term impacts on the human throat and gut microbiome. PLoS One. 2010 Mar 24;5(3):e9836. doi: 10.1371/journal.pone.000983 — View Citation

Lopo I, Libânio D, Pita I, Dinis-Ribeiro M, Pimentel-Nunes P. Helicobacter pylori antibiotic resistance in Portugal: Systematic review and meta-analysis. Helicobacter. 2018 Aug;23(4):e12493. doi: 10.1111/hel.12493. Epub 2018 Jun 17. Review. — View Citation

Malfertheiner P, Megraud F, O'Morain CA, Gisbert JP, Kuipers EJ, Axon AT, Bazzoli F, Gasbarrini A, Atherton J, Graham DY, Hunt R, Moayyedi P, Rokkas T, Rugge M, Selgrad M, Suerbaum S, Sugano K, El-Omar EM; European Helicobacter and Microbiota Study Group — View Citation

Myllyluoma E, Ahlroos T, Veijola L, Rautelin H, Tynkkynen S, Korpela R. Effects of anti-Helicobacter pylori treatment and probiotic supplementation on intestinal microbiota. Int J Antimicrob Agents. 2007 Jan;29(1):66-72. Epub 2006 Dec 1. — View Citation

Satoh Y, Ogawara H, Kawamura O, Kusano M, Murakami H. Clinical Significance of Peripheral Blood T Lymphocyte Subsets in Helicobacter pylori-Infected Patients. Gastroenterol Res Pract. 2012;2012:819842. doi: 10.1155/2012/819842. Epub 2012 Mar 28. — View Citation

Savoldi A, Carrara E, Graham DY, Conti M, Tacconelli E. Prevalence of Antibiotic Resistance in Helicobacter pylori: A Systematic Review and Meta-analysis in World Health Organization Regions. Gastroenterology. 2018 Nov;155(5):1372-1382.e17. doi: 10.1053/j — View Citation

Song M, Rabkin CS, Torres J, Kemp TJ, Zabaleta J, Pinto LA, Hildesheim A, Sánchez-Figueroa L, Guarner J, Herrera-Goepfert R, Parsonnet J, Camargo MC. Circulating inflammation-related markers and advanced gastric premalignant lesions. J Gastroenterol Hepat — View Citation

Wang AY, Peura DA. The prevalence and incidence of Helicobacter pylori-associated peptic ulcer disease and upper gastrointestinal bleeding throughout the world. Gastrointest Endosc Clin N Am. 2011 Oct;21(4):613-35. doi: 10.1016/j.giec.2011.07.011. Review. — View Citation

Yap TW, Gan HM, Lee YP, Leow AH, Azmi AN, Francois F, Perez-Perez GI, Loke MF, Goh KL, Vadivelu J. Helicobacter pylori Eradication Causes Perturbation of the Human Gut Microbiome in Young Adults. PLoS One. 2016 Mar 18;11(3):e0151893. doi: 10.1371/journal. — View Citation

Zamani M, Ebrahimtabar F, Zamani V, Miller WH, Alizadeh-Navaei R, Shokri-Shirvani J, Derakhshan MH. Systematic review with meta-analysis: the worldwide prevalence of Helicobacter pylori infection. Aliment Pharmacol Ther. 2018 Apr;47(7):868-876. doi: 10.11 — View Citation

* Note: There are 28 references in allClick here to view all references

Outcome

Type Measure Description Time frame Safety issue
Other Post-eradication changes assessed by immunological cells populations in immunological profile Fresh peripheral blood samples will be collected and analyzed on 2 occasions: 1) baseline and 2) 12 months after treatment. A standard protocol with the conditions of collection, storage and transport of the different collected samples will be used. Analysis of immunological changes: Immunological profile will be analysed through the study of cell populations (CD4+, CD8+, B-cell, T-cell, natural killer cells, cells ratio) by multiparametric flow cytometry, before and 12 months after the H. pylori eradication therapy, by an independent operator who does not know the therapeutic scheme used. Changes from baseline at 12 months after the intervention
Other Post-eradication changes assessed by cytokines, chemokines and growth factors in immunological profile Fresh peripheral blood samples will be collected and analyzed on 2 occasions: 1) baseline and 2) 12 months after treatment. A standard protocol with the conditions of collection, storage and transport of the different collected samples will be used. Analysis of immunological changes: Immunological profile will be analysed through the study of cytokines, chemokines and growth factors by xMAP/Luminex, before and 12 months after the H. pylori eradication therapy, by an independent operator who does not know the therapeutic scheme used. Changes from baseline at 12 months after the intervention
Primary Efficacy assessed by the eradication rate of the different therapeutic regimens recommended as H. pylori eradication therapy Efficacy rate of H. pylori eradication will be determined for five different therapeutic regimens (sequential, hybrid and concomitants with or without bismuth). A successful eradication implies no documentation of H. pylori by carbon 13-labeled urea breath test or upper gastrointestinal endoscopy with biopsies, depending on clinical indication, at 1 month after H. pylori eradication (D40 or D44). A therapeutic regimen will be considered effective if it achieves more than 90% of H. pylori eradication (the minimum efficacy rate). 1 month after the intervention
Primary Efficacy assessed by the re-infection rate after the different therapeutic regimens recommended as H. pylori eradication therapy At 12 months after H. pylori eradication, a carbon 13-labeled urea breath test will be performed to exclude re-infection. 12 months after the intervention
Primary Safety assessed by overall treatment-adverse events and and severe treatment-adverse events rates of the different therapeutic regimens recommended as H. pylori eradication therapy Safety profile of H. pylori eradication will be determined for five different therapeutic regimens measuring adverse effects according to Medical Dictionary for Regulatory Activities (MedDRa). Therapy-related adverse events and its severity (by visual analogue scale of intolerance [0-10] and classification of the severity of adverse effects for the daily life activities according to [BoThBo96]) will be recorded at 1 month post-eradication follow-up. 1 month after the intervention
Primary Safety assessed by overall treatment completion rate of the different therapeutic regimens recommended as H. pylori eradication therapy Safety profile of H. pylori eradication will be determined for five different therapeutic regimens measuring the treatment completion rate to the treatment at 1 month post-eradication follow-up. 1 month after the intervention
Secondary Post-eradication changes assessed by OTU and their relative abundance in gut microbiota Stool samples shall be collected, stored at -20°C and then analyzed on 3 occasions: 1) baseline, 2) after stopping treatment (D10 or 14) and 3) 1 month after treatment (D40 or 44). A standard protocol with the conditions of collection, storage and transport of the different collected samples will be used. Analysis of gut microbiota by DNA sequencing using the hypervariable region of the 16S ribosomal bacteria gene as a taxonomic identification marker by bioinformatic analysis, for taxonomic identification and determination of the relative abundance of each Operational Taxonomy Units (OTU). The gut microbiota will be evaluated by an independent operator who does not know the therapeutic scheme used. Changes from baseline at immediately after the intervention
Secondary Post-eradication changes assessed by OTU and their relative abundance in gut microbiota Stool samples shall be collected, stored at -20°C and then analyzed on 3 occasions: 1) baseline, 2) after stopping treatment (D10 or 14) and 3) 1 month after treatment (D40 or 44). A standard protocol with the conditions of collection, storage and transport of the different collected samples will be used. Analysis of gut microbiota by DNA sequencing using the hypervariable region of the 16S ribosomal bacteria gene as a taxonomic identification marker by bioinformatic analysis, for taxonomic identification and determination of the relative abundance of each Operational Taxonomy Units (OTU). The gut microbiota will be evaluated by an independent operator who does not know the therapeutic scheme used. Changes from baseline at 1 month after the intervention
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