Morozov

Structural-Functional Grounding of Optimal Eradication Conditions of the

Helicobacter pylori Infection in the Stomach

Morozov I.A.

M.D., professor, member of the Russian Academy of Natural Sciences, Head of laboratory of Pathomorphology of viral diseases, Deputy Director for research of the M.P.Chumakov FGBU Institute of Poliomyelitis and Viral Encephalitis of the Russian Academy of Medical Sciences, has 12 monographs, 400 research papers.

Intensive studies, conducted over the last decade in relation to the infection Helicobacter pylori (Hр) in the stomach, resulted not only in the deciphering of the bacterium genome, but also in the identification of structural-functional characteristics at the molecular level, pathogenic and metabolic properties which define interrelations between the infectious organism and a human body. It is established [4] that such pathogenic property as cytotoxicity can be modified during the persistence of the infectious organism as a result of the microorganism mutation and therefore is not critical for the direction and nature of the pathology development. Cytotoxicity only determines the severity and intensity of the inflammatory process which arises every time Hp gets into a human stomach. Attempts to identify ulcerogenic and carcinogenic strains were not successful. A growing number of evidence show that after the infection of a human stomach with Hp, further cause of events depends not only on the characteristics of the microorganism strain, but also on ethno-geographical, phenotypic, and genotypic properties of the infected patient. In most cases the process of HP-infection is asymptomatic, which proves the validity of M.Blaster’s opinion [13, 14] who thought that depending on the environmental conditions, HP may not only be the pathogen, but the commensal as well. However, morphological signs of inflammation in the presence of Hp infection are always detected, even in the absence of any patient complaints.

Despite significant progress in the study of molecular and genetic characteristics of Helicobacter microorganisms and their possible participation in the formation of liver and bladder pathologies, the progress in the infection eradication (destruction) is extremely modest. In contrast to clinical trials of different drugs combinations in urgent therapy, the efficiency of the eradication of the infectious organism does not exceed 60-65%. Due to this, in international and national recommendations there are concepts of “first” and “second line” therapies. There are even suggestions to use “third line” therapy if there’s clinical deterioration after the first two. Starting in 1996 in Maastricht, the leading experts of the European Helicobacter Study Group on the basis of previous studies of drugs and eradication schemes of the infectious organism provide recommendations for general practitioners and gastroenterologists in EU countries. These recommendations are the basis for national standards that particularly take into account the presence of Hp strains, resistant to the main drugs used for eradication. These recommendations have been reviewed three times recently, but the core guidelines laid down in Maastricht-2 remain unchanged. The message about the Maastricht-4 consensus [19] published in Gat at the end of April this year, proves lack of significant progress in the fight against Hp-infection. Experts with obsessive stubbornness continue prescribing the same drugs, used for more than 15 years and the number of resistant Hp strains to which equals 20-65%: clarithromycin, metronidazole, tetracycline, etc. The only achievement of the two last consensuses is the possibility to use quadruple therapy or bismuth-containing quadruple therapy as first-line therapy, but with the eradication course duration increased up to 10-14 days. However, it’s doubtful that this may lead to significant effects as during the dynamic monitoring of duodenal ulcer scarring after bleeding and Hp eradication it was demonstrated that if the infectious organism is not destroyed after 5 days of treatment, further eradication therapy is meaningless [7].

There are objective reasons decreasing the efficiency of modern treatment schemes of acid-related disorders during Hp eradication in stomach. Firstly, for many years the same antibiotics, created for the treatment of pneumonia and urogenital infections, but not specific for stomach Hp-infection, are used. As these drugs are used for intended purposes as monotherapy, the number of strains resistant to them progressively increases. For example, in Russian conditions the use of metronidazole in eradication schemes of the “first” and “second lines” is completely useless as the number of stains resistant to this drug has reached 65% [4].

Secondly, the competitive advantages of hydrogen pump inhibitors (PPI) to H₂-receptor blockers of parietal cells to histamine are unreasonably hypertrophied when used in treatment schemes as “basic drugs”. They are even attributed synergism properties with clarithromycin at Hp eradication [2], although it’s nothing but the demonstration of protection of the antibiotic, which is unstable in the acid environment to inactivation and destroy [16]. In clinical and ambulatory practice PPI are used almost without preliminary testing of the patients’ response to such kind of drugs, despite the fact that about 20% of human population are insensitive to them and 70% after two doses of PPI experience “nocturnal acid breakthroughs” [8]. This can a priori lower the upper limit of the eradication efficiency below 80% when used in clarithromycin schemes, which is quickly inactivated in the acid environment. Due to this, the use of clarithromycin in triple schemes together with De-Nol as the basic drug, instead of acid secretion inhibitors, as suggested by some researches [9], is meaningless. The efficiency check of such schemes demonstrates disappointingly low results of eradication.

It was repeatedly demonstrated that quadruple treatment schemes are more effective at Hp-infection eradication. It was many times suggested [10, 11, 17] to use similar schemes as “first-line” therapy. The only argument of the opponents of this approach was the claim that the use of quadruple schemes is accompanied by many undesirable side effects [2]. However it’s possible to form such quadruple schemes, the use of which will have minimal side effects during therapy.

Thirdly, persistence of the infectious organism deep in the near-wall mucus layer, the hydrophobic surface of which prevents drugs penetration, is not taken into account [1, 3]. The mucus layer is not an obstacle for Hp as it makes its environment. Even at the adhesion of germinal epithelium to the surface of the apical membrane, the remaining surface of the bacterium is submerged in the mucin gel of the mucus layer (Fig. 1). In the depth of this layer Hp chooses zones with pH = 6-7 where it can extensively proliferate. The mucus layer is constantly renovated, growing on the inside due to mucin secretion by surface epithelial cells and exfoliating from the luminal surface.

Fig. 1 Helicobacter pylori in the near-wall zone of the antrum mucus layer.

Explanations in the text. Zooming х15 000

Hp bacteria in the layer are partially off together with the exfoliating mucus and are further found in the feces of infected patients. PCR diagnostics of Hp-infection in feces is based on this property. The bacteria remaining in the mucus layer move to the optimal pH zone by chemotaxis. Many people still believe that anti-helicobacter drugs function by being absorbed in the small intestine and creating high concentrations in stomach tissues or after the excretion in its lumen. However, such drugs as clarithromycin and amoxicillin, initially created to treat pneumonia, produce highest concentrations in lung tissues, whereas their concentration in stomach tissues is 4 times lower [15], and excretion to stomach does not exceed 1% of the given dose.

Fourthly, the use of tablet drugs does not allow impacting the whole surface of the stomach mucus layer. It’s particularly important to mention the pharmacologists’ opinion, according to which liquid forms of antibiotics (suspensions, syrups) are most efficient [5]. Later eating after a short period of time does not aid eradication. When about 10 years ago we thought of conducting Hp eradication by drugs solutions, we didn’t find any publications on the subject. From personal conversations with many clinicians we found out that some researchers tried to use water solutions of ground tablets but didn’t experience significant efficiency improvement in the eradication of the infectious organism and thus didn’t publish these results. As in the 70-80s of the twentieth century there was intensive research of the structure and functional properties of the near-wall mucus layer of the digestive tract, it was established that the luminal surface of this layer is charged and hydrophobic, thus preventing the liquid from diffusing deep into the layer. At the same time, during the breath test to diagnose Hp-infection with ¹³C-urea labeled with stable isotope, dissolved in orange juice, the stomach mucus layer does not oppose its rapid diffusion and interaction with Hp. The use of orange juice was in this case justified by the presence of citric acid, which delays liquid evacuation from the stomach and lengthens interaction of the infectious organism with ¹³С-urea. However, this effect is very weak, which suggests the presence of another factor facilitating the diffusion of the liquid and substances, dissolved in orange juice. The experimental check of open rats’ stomachs demonstrated that organic components of orange juice have affinity to the surface of the mucin layer and being actively absorbed on it neutralize the charge and make the mucus surface hydrophilic. The only juice components with such an affinity to the mucin gel of the mucus layer, are gel pectin solutions, the content of which in the juice is high enough (2,0-3,0 g/l). If a patient doesn’t want or doesn’t accept orange juice, other unclarified juices can be used (apricot, peach, plum), the content of pectins in which is comparable to the orange juice, and pH by citric and apple acids is about 4,5. To prolong interaction of the stomach mucous coat and drugs solution, topographic and anatomical stomach properties can be used; and the eradication procedure can be carried out when the patient lies on the left side, when the pyloric channel is up which significantly hampers fluids evacuation.

Like pectin, colloidal bismuth substrate (De-Nol) has the same affinity to the new gel. About 25 years ago in the Central Research Institute of Gastroenterology, L.I.Aruin, A.A.Ilchenko and V.B. Potapova studied the mechanism of De-Nol interaction with the stomach mucous coat. During the study in the scanning microscope it was found out that supramolecular drug globules are adsorbed on the mucus surface (personal message, unpublished data) (Fig. 2а), from where the colloidal bismuth subcitrate diffuses into the HP source zone and interacts with it (Fig. 26). If a patient did not eat after the drug administration, the mentioned complexes are preserved on the mucosal surface even after 12 hours, which contradicts the claims that the drug completely disappears from the mucosal surface in an hour [5]. It’s worth mentioning that the colloidal bismuth subcitrate (De-Nol) when released by the Yamanouchi company, was produced as colloidal suspension instead of tablets. Currently, it is designated in all reference materials by the chemical formulae “Bismuthate tripotassium dicitrate”.

Fig. 2 Interaction of colloidal bismuth subcitrate (De-Nol) with the stomach mucous coat and Нр. а) Supramolecular complexes (globules) of the colloidal bismuth subcitrate on the surface of a human stomach mucus 12 hours after the drug administration. SEM. Zoom х3000. (by courtesy of A.A.Ilchenko) b) Bismuth persorption (De-Nol) on the surface Нр in the mucus layer. TEM. Zoom х20000.

Since Hp eradication is mostly conducted in the treatment of ulcer disease, associated with this infection, which is as a rule accompanied by the pain syndrome, treatment schemes include drugs that inhibit the secretion of hydrochloric acid. The choice should be based on drugs’ qualities that provide optimal therapy conditions, i.e. rapid pain relief, effective scarring of the ulcer defect, and complete destruction of bacillary and coccal Hp forms in the stomach. Regarding the pain relief, inhibitors N⁺/К⁺-АТPhase, and Н₂-receptor blockers of parietal cells to histamine are almost equivalent, which is proved by multiple publications. The speed of ulcer defects scarring at adequate treatment depends on the size of ulcers; and at the eradication of the Hp-infection is similar for both groups of hydrochloric acid secretion inhibitors, whereas if the infection is preserved, ulcer defects heal 4-7 days faster when Н₂-receptor blockers of parietal cells to histamine are used. This is clearly seen when the treatment starts at the peak of ulcer development at bleeding [7]. Apparently, more efficient scarring using blockers of histamine Н₂-receptors depends on their antioxidant effect [12], on the reduction of reactive oxygen species production by the infectious organism [18], and by the neutrophils of the stomach lamina propria; and, consequently, the reduction of the inflammatory reaction intensity. Besides, it should be taken into account that inhibitors N⁺/К⁺-АТPhase, suppressing the production of hydrochloric acid during the active phase of digestion (as well as basal) by 85-95%, inhibit the gastric phase of the proteolytic cascade and lead to the protein fixing reduction by 25-30% [6]. This affects deterioration of the reparative processes supply with plastic material. Given the above, the use of Н₂-receptors blockers of parietal cells to histamine when treating the ulcer disease, is preferable.

To overcome the above mentioned reasons of low efficiency of the eradication therapy we offered a new methodological approach, based on the use of:

1. Quadruple eradication schemes as “first-line” therapy.

1. Н₂-receptors blockers of parietal cells to histamine to reduce hydrochloric secretion and suppress production of reactive oxygen species by the infectious organism and neutrophils of the stomach lamina propria.
2. Antibacterial drugs and antibiotics, to which Hp resistance is not produced and which may act in a wide pH range.
3. “Liquid” technology, assuming the dissolution of ground tablets of anti-helicobacter drugs in sufficient quantities of orange juice.

In the scheme of the quadruple anti-helicobacter therapy, famotidine (kvamatel), the blocker of histamine Н₂-receptors of the third generation in the standard dose of 20 mg, is included. Its use can be omitted if the eradication therapy is conducted during the intercritical period of the disease.

As eradication remedies we propose the inclusion of those which can actively influence the infectious organism (Hp), act in a wide pH range and to which no resistance is produced: Amoxicillin (Flemoksin Solutab) – 1000 mg, De-Nol - 240 mg and Nifuratel (Makmiror) – 400 mg or Enterofuril – 400 mg per administration. Out of Nitrofuran drugs, Enterofuril is preferred, which is produced as liquid emulsion. The abovementioned drugs after fine grinding are dissolved in 120-150 ml of orange (or other unclarified) juice.

The treatment procedure is conducted in the following way. An hour before eating a patient takes a pill of Famotidine (if this is necessary) with some water. After 30 minutes he drinks a prepared solution of the abovementioned anti-helicobacter drugs in juice. After drinking the solution, the patient lies down on the left side, turning on stomach every 2-4 minutes, and returning to previous position. The patient may eat 30 minutes later. Eradication therapy lasts one week. The control Hp check is carried out 4-6 weeks on completing the administration of anti-helicobacter and anti-secretion drugs. The efficiency of treatment and reliable eradication of the infectious organism (Hp) is achieved not only by the influence of the drugs solution on the whole surface of the stomach mucous coat for a long time (which is extremely important), but also by overcoming hydrophobic properties of the mucus layer surface and providing drugs diffusion deep into this layer directly into the persistence zone of the infectious organism (Hp).

Preliminary results demonstrated significant increase of eradication efficiency when using fluid technology of administration of anti-helicobacter drugs, possibility to shorten therapy periods and significant reduction of financial expenses. Independent testing of the liquid technology using the abovementioned quadruple scheme in the medical centers of Tver and Khabarovsk confirm almost 100% eradication efficiency when using three verification methods of the Hp-infection before and after the treatment. The results of testing in 2004 were reported at the European congress of H.pylori in Vienna [20] and found understanding and approval of B.J.Marshall and D.Grechem. The priority patent No.2 253449 for the liquid eradication technology was granted on the 13-th of November, 2003. The method is not only very well perceived by patients and has very few adverse side effects, but is also more advantageous from the pharmaeconomical point of view compared to traditional standard methods and schemes. Undoubtedly, the liquid technology is very perspective for application not only for Hp eradication in adult patients, but also in pediatric gastroenterology.

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