Recap and review the top pearls from recent episodes #322 H. Pylori and #324 Obesity Medicine FAQ with Watto and Paul. It’s Tales from the Curbside! (TFTC), our monthly series providing a rapid review of recent Curbsiders episodes for your spaced learning.
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Featuring Dr. George Saffouri and production and graphics by Beth Garbitelli
H. pylori infection is often acquired in childhood (Kavitt 2017). While H. pylori is reported as ‘low prevalence’ in the United States, other global regions have a higher prevalence. As such, some guidelines recommend screening first-generation immigrants from high prevalence countries (El-Serag 2018).
Helicobacter pylori (h.pylori) infection may present with non-specific abdominal pain, gas, bloating, belching, postprandial fullness, and other symptoms suggestive of dyspepsia (Diaconu 2017). Red flags include bleeding and unintentional weight loss. GERD (heartburn symptoms) can be empirically treated with a PPI, but best to test then treat in patients with dyspepsia since treatment of H. pylori can reduce cancer risk (Crowe 2019, Chey 2017).
Patients over 60 years old need an endoscopy. Patients under 60 years old without red flags can be evaluated with either stool antigen or breath testing. H. pylori serologies are used less often since they don’t clearly indicate active infection.
Before testing, patients should be off of proton pump inhibitors (Crowe 2019), antibiotics, and probably H2 receptor antagonists (Graham 2004) for a month (per Dr Saffouri’s practice, but the guidelines indicate 1-2 weeks off PPI and four weeks off antibiotics, Chey 2017). Kashlak pearl: Okay to use antacids (e.g., calcium carbonate) before testing.
Based on (Crowe 2019, Chey 2017).
Counsel patients that while side effects (nausea, vomiting, diarrhea) are probable, treatment adherence is paramount, as H. pylori is associated with MALToma and gastric cancer.
Do not use clarithromycin-based triple therapy, given the high rates of clarithromycin resistance (Huang 2017). Instead, choose bismuth-based quadruple therapy (bismuth + PPI + tetracycline + metronidazole) as a starting regimen. N.b. side effects are common (Huang 2017, Chey 2017).
Saffouri’s Antibiotic Recs:
At ACP #IM2022, Dr. Brooks Cash discussed rifabutin-containing therapy (rifabutin + omeprazole + amoxicillin, Graham, 2022), vonoprazan-containing therapy (vonoprazan + amoxicillin +/- clarithromycin), or reverse hybrid therapy (PPI + amoxicillin for 14 days with the addition of clarithromycin and metronidazole for the final seven days) as emerging winners (Rokkas, 2021) due to increasing resistance to clarithromycin, metronidazole, and fluoroquinolones.
Featuring Dr. Fatima Cody-Stanford and production and graphics by Isabel Valdez, PA
Lifestyle changes (diet and exercise) are often insufficient to meet a patient’s weight loss needs. Dr. Stanford offers the analogy of using a spoon to shovel your driveway. In this analogy, medications would be like using a shovel. They provide varying amounts of weight loss ranging from 5 to 15 percent (approximation). Finally, metabolic surgeries are like a snow plow and can lead to drastic weight loss.
Dr. Stanford notes that even after metabolic surgery, patients might plateau or start to regain weight. In these cases, patients might go for another surgery (e.g. Roux-en-Y) or start medications to assist with weight loss.
“We are not reticent to consider medication for any other chronic disease whether it be diabetes or hypertension…but only about 1% of individuals that meet criteria for medications[…] are actually on medications for the treatment of obesity.”
–Dr. Fatima Cody Stanford (Claridy 2021)
There are several FDA-approved medications for weight loss (orlistat, phentermine/topiramate, bupropion, naltrexone, GLP1 agonists, and soon, tirzepatide, a combined GIP/GLP1 agonist (Jastreboff 2022). Dr. Stanford does not prescribe combination pills due to the cost and risk of side effects. Instead, she starts at low doses of a given med and titrates over weeks to months. A second medication can be added in combination if goals are not met.
Take phentermine in the morning. Normal dose is 15-37.5 mg. Start low and increase every three months as needed. Monitor blood pressure (BP) and heart rate (HR) three times weekly when starting. N.b. Some states restrict long-term prescribing (e.g. three-month limit). –expert opinion
Take topiramate in the evening to accommodate cognitive side effects. Start with 25 mg and titrate up. Max dose 150 mg/day –expert opinion. Contraindicated if the patient has a history of nephrolithiasis.
More likely to elevate BP and HR than phentermine (Roose 1991, Thase 2008, Siebenhofer 2009)! Start bupropion SR 150 mg twice daily and then titrate up to max two tabs in AM (300 mg) and one tab in PM (150 mg) –expert opinion.
Start naltrexone 50 mg tabs at one-quarter tab daily and then titrate up by one-quarter tab weekly until taking half a tab (25 mg) twice daily (expert opinion). Kashlak pearl: Naltrexone can be used in combination with bupropion to approximate the branded combo pill.
Semaglutide weekly and liraglutide daily are FDA approved. Doses are slowly titrated to mitigate GI side effects. Semaglute 2.4 mg weekly provided nearly 15% weight loss.
We did not discuss it in this episode, but tirzepatide is FDA approved for type 2 diabetes, and we expect FDA approval for obesity soon. It provided 20 percent weight loss for more than half of the patients taking 10-15 mg weekly (SURMOUNT-1)!
N.b., the meds mentioned above are not recommended in pregnancy! Dr. Stanford recommends stopping GLP-1 agonists two months prior to planned conception (expert opinion).
Listeners will recall key pearls from recent Curbsiders episodes
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Williams PN, Watto MF. “#352 H. pylori and Obesity Medicine FAQ: A rapid review (TFTC)”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date August 31, 2022.
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