Atorvastatin in combination with conventional antimicrobial treatment of Helicobacter pylori eradication: A randomized controlled clinical trial

Statins, Allies against Antibiotic Resistance?

Due to the ever-increasing rate of antibacterial resistance, the search for effective antibacterial agents has become imperative. Researchers have investigated the potential antimicrobial properties of various classes of nonantibiotic drugs. Statins are a group of antihyperlipidemic drugs with several cholesterol-independent effects, including antiinflammatory, immune-modulating, antioxidant, and antibacterial effects. In vitro and in vivo studies have demonstrated the antibacterial properties of statins against various grampositive and gram-negative bacteria. Simvastatin and atorvastatin are the most potent members of the family. Their antibacterial effect can be attributed to several direct and indirect mechanisms. Bacterial invasion, growth, and virulence are affected by statins. However, since in vitro minimum inhibitory concentrations (MICs) are significantly higher than serum concentrations at the lipid-lowering dosage, indirect mechanisms have been suggested to explain the positive clinical results, including reducing inflammation and improving immune response capacity. Further, statins have shown promising results when combined with antibiotics and other antibacterial agents, such as triazenes and silver nanoparticles. Despite this, the controversial aspects of statins have cast doubt on their efficacy as a possible solution for antibacterial resistance, and further research is required. Consequently, this review will examine in detail the current clinical and in vitro findings and controversies regarding statins' antibacterial properties and their relevance to antibacterial resistance.

Unveiling the Antibacterial Properties of Statins: An In Vitro Study on Helicobacter pylori

Background

Helicobacter pylori (H. pylori), a widespread bacterial pathogen, is associated with various gastrointestinal diseases, including gastric cancer. Statins, widely prescribed cholesterol-lowering agents, have demonstrated pleiotropic effects, including potential antimicrobial properties. This in vitro study investigated the direct antibacterial effects of three clinically approved statins, simvastatin, atorvastatin, and rosuvastatin, against H. pylori isolates.

Methods

H. pylori strains were isolated from gastric biopsies of dyspeptic patients and identified by microbiological techniques. The minimum inhibitory concentrations (MICs) of statins were determined using the agar dilution method, and their antimicrobial activity was evaluated by the disc diffusion method using different concentrations of simvastatin, atorvastatin, rosuvastatin, tetracycline, and amoxicillin. Scanning electron microscopy (SEM) was employed to examine the morphology of H. pylori cells.

Results

The minimum inhibitory concentration (MIC) values (μg/mL) of atorvastatin, rosuvastatin, simvastatin, tetracycline, and amoxicillin against H. pylori were 240 ± 20, 450 ± 20, 460 ± 15, 155 ± 30, and 140 ± 20, respectively. In the disc diffusion assay, atorvastatin and rosuvastatin produced significantly larger inhibition zones compared to simvastatin at all concentrations tested (p < 0.05). The inhibition zone diameters (mm) increased with higher statin concentrations, ranging from 9 ± 1.4 to 13 ± 1.4 for atorvastatin, 8 ± 0.9 to 11 ± 0.6 for rosuvastatin, and 5 ± 1.3 to 6 ± 1.4 for simvastatin at the highest tested concentration (1200 μg/ml). SEM analysis revealed the characteristic spiral morphology of H. pylori cells.

Conclusion

Statins demonstrated varying degrees of antibacterial activity against H. pylori isolates, with atorvastatin exhibiting the highest potency. While the observed effects were lower than those of conventional antibiotics, these findings suggest the potential of statins as adjunctive agents or alternative therapeutic options, warranting further investigation through in vivo studies and clinical trials.

An Update on Eradication of Helicobacter Pylori in Iran: A Review

Background

Helicobacter pylori, the most prevalent infection in the world, has great importance due to being related to peptic ulcer disease, gastric metaplasia, dysplasia, and even gastric adenocarcinoma or mucosa-associated lymphoid tissue (MALT) lymphoma. The standard H. pylori eradication regimen is based on antibiotic susceptibility testing. If susceptibility testing is not available, a standard treatment regimen will be recommended based on records of H. pylori resistance rates to antibiotics in a region or locally proven highly effective regimens (equal to or higher than 90% eradication rate). The aim of this review was to define suitable recommendations for local treatment in different cities of Iran.

Methods

This review article consists of randomized controlled trials related to H. pylori eradication in Iran. Data including the kind of therapy, number of patients and per-protocol H. pylori eradication rates were recorded in data gathering forms. Data search was conducted in PubMed and Google Scholar databases from 2018 to December 2023.

Results

According to our review of Iranian articles regarding first-line H. pylori eradication regimens, these treatment protocols could be recommended: Bismuth-clarithromycin quadruple therapy in Ardabil, bismuth-clarithromycin quadruple therapy with probiotics in Birjand, standard triple therapy in Ilam, bismuth quadruple therapy or bismuth triple therapy or concomitant regimen in Sari, sequential therapy in Tehran and bismuth quadruple therapy in Yazd. These regimes can be extended to other regions that have a similar situation. According to the reports of Iranian researchers, a quinolone-containing regimen (levofloxacin preferred) is recommended for second-line eradication therapy.

Conclusion

Various H. pylori eradication regimens can be used as first-line therapy; however, choices for second-line therapy are limited. We recommend the quinolone-containing regimens as the preferred second-line therapy.

Effect of statin use on risk and mortality of gastric cancer: a meta-analysis

The effect of statins on gastric cancer risk is still controversial. And studies on the association between statins and gastric cancer mortality are very limited. Therefore, we conducted this systemic review and meta-analysis to evaluate the association between the use of statin and gastric cancer. Searched studies were published before November 2022. Odds ratios (ORs)/relative risks (RRs) or hazard ratios (HRs) and their 95% confidence intervals (CIs) were computed using STATA 12.0 software. The study showed that the statin use group showed a significantly lower risk of gastric cancer, compared to no statin use group (OR/RR, 0.74; 95% CI: 0.67-0.80, P  < 0.001). The study showed that the statin use group showed significantly lower all-cause mortality and cancer-specific mortality of gastric cancer, compared to no statin use group (all-cause mortality: HR, 0.70; 95% CI: 0.52-0.95, P  = 0.021; cancer-specific mortality: HR, 0.70; 95% CI: 0.58-0.84, P  < 0.001). Overall, results from this meta-analysis showed the protective effect of statins exposure on the risk and prognosis of gastric cancer; however, we still need more well designed, large-scale studies and randomized clinical trials to pinpoint the effect of statins on gastric cancer in future clinical practice.

Management of Helicobacter pylori infection

Helicobacter pylori infection exhibits a wide disease spectrum ranging from asymptomatic gastritis, peptic ulcer disease, to gastric cancer. H. pylori can induce dysbiosis of gastric microbiota in the pathway of carcinogenesis and successful eradication can restore gastric homeostasis. Diagnostic testing and treatment for H. pylori infection is recommended in patients with active or past history of peptic ulcer, chronic dyspepsia, chronic non-steroidal anti-inflammatory drugs (NSAID) or aspirin use, precancerous gastric lesions, gastric cancer, mucosa-associated lymphoid tissue (MALT) lymphoma, family history of gastric cancer, family history of peptic ulcers, household family member having active H. pylori infection, iron deficiency anemia, idiopathic thrombocytopenic purpura, or vitamin B12 deficiency. Recommended first-line regimens for H. pylori eradication are classified according to clarithromycin resistance. In areas of high clarithromycin resistance (≥15%), we recommend 14-day concomitant therapy or 14-day bismuth quadruple therapy (BQT) as first-line regimen. In areas of low clarithromycin resistance (<15%), we recommend 14-day triple therapy or 14-day BQT as first-line treatment. Second-line regimens are 14-day levofloxacin triple therapy or 14-day BQT if BQT is not previously used. For patients with multiple treatment failure, antimicrobial susceptibility testing (AST) should be performed. If AST is not available, we recommend using antibiotics not previously used or for which resistance is unlikely, such as amoxicillin, tetracycline, bismuth, or furazolidone. High-dose potent proton pump inhibitor or vonoprazan is recommended to achieve adequate acid suppression. Probiotics can be used as an adjuvant treatment to reduce the side effects of antibiotics and enhance eradication rate.

Effect of Statins on Helicobacter pylori Eradication Rate: A Systematic Review and Meta-Analysis

Statins have been used as adjuvants to standard treatment in order to increase the eradication rates of Helicobacter pylori infection. This study aimed to summarize the results of the efficacy of adding statins to standard treatments used for the eradication of H. pylori infection. We conducted a systematic search using a comprehensive combination of keywords in PubMed/MEDLINE, Web of Science, and Scopus to retrieve relevant studies from 1990 to 2020. The estimate of pooled relative risk (RR), as the effect measure, was calculated using random effects meta-analyses in Stata 14. We finally included 5 studies (all of them were randomized controlled trials). The meta-analysis of all studies showed that the pooled RR (95% confidence interval) was 1.03 (0.64-1.68) in the random effects model, which was not statistically significant. In other words, based on our meta-analysis, the addition of statins as an adjuvant therapy to the standard treatment regimens does not increase the rate of H. pylori eradication. However, further evidence is needed to confirm this result as the number of available studies was small.

Current and Future Perspectives in the Diagnosis and Management of Helicobacter pylori Infection

Helicobacter pylori (Hp) is a prevalent organism infecting almost half the global population. It is a significant concern, given its associated risk of gastric cancer, which is the third leading cause of cancer death globally. Infection can be asymptomatic or present with dyspeptic symptoms. It may also present with alarm symptoms in the case of progression to cancer. Diagnosis can be achieved non-invasively (breath tests, stool studies, or serology) or invasively (rapid urease test, biopsy, or culture). Treatment involves acid suppression and regimens containing several antibiotics and is guided by resistance rates. Eradication is essential, as it lowers the risk of complications and progression to cancer. Follow-up after eradication is similarly important, as the risk of cancer progression remains. There have been many recent advances in both diagnosis and treatment of Hp. In particular, biosensors may be effective diagnostic tools, and nanotechnology, vaccines, and potassium-competitive acid blockers may prove effective in enhancing eradication rates.

Non-Antibiotic Drug Repositioning as an Alternative Antimicrobial Approach

The worldwide scenario of antibiotic resistance and the falling number of funds for the development of novel antibiotics have led research efforts toward the study of specific cost-effective strategies aimed at discovering drugs against microbial infections. Among the potential options, drug repositioning, which has already exhibited satisfactory results in other medical fields, came out as the most promising. It consists of finding new uses for previously approved medicines and, over the years, many “repurposed drugs” displayed some encouraging in vitro and in vivo results beyond their initial application. The principal theoretical justification for reusing already existing drugs is that they have known mechanisms of action and manageable side effects. Reuse of old drugs is now considered an interesting approach to overcome the drawbacks of conventional antibiotics. The purpose of this review is to offer the reader a panoramic view of the updated studies concerning the repositioning process of different classes of non-antibiotic drugs in the antimicrobial field. Several research works reported the ability of some non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants, antipsychotics, and statins to counteract the growth of harmful microorganisms, demonstrating an interesting winning mode to fight infectious diseases caused by antimicrobial resistant bacteria.

Beyond Lipid-Lowering: Effects of Statins on Cardiovascular and Cerebrovascular Diseases and Cancer

The 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors, also known as statins, are administered as first-line therapy for hypercholesterolemia, both as primary and secondary prevention. Besides the lipid-lowering effect, statins have been suggested to inhibit the development of cardiovascular disease through anti-inflammatory, antioxidant, vascular endothelial function-improving, plaque-stabilizing, and platelet aggregation-inhibiting effects. The preventive effect of statins on atherothrombotic stroke has been well established, but statins can influence other cerebrovascular diseases. This suggests that statins have many neuroprotective effects in addition to lowering cholesterol. Furthermore, research suggests that statins cause pro-apoptotic, growth-inhibitory, and pro-differentiation effects in various malignancies. Preclinical and clinical evidence suggests that statins inhibit tumor growth and induce apoptosis in specific cancer cell types. The pleiotropic effects of statins on cardiovascular and cerebrovascular diseases have been well established; however, the effects of statins on cancer patients have not been fully elucidated and are still controversial. This review discusses the recent evidence on the effects of statins on cardiovascular and cerebrovascular diseases and cancer. Additionally, this study describes the pharmacological action of statins, focusing on the aspect of ‘beyond lipid-lowering’.

The Role of Statins on Helicobacter pylori Eradication: Results from the European Registry on the Management of H. pylori (Hp-EuReg)

Statins could increase the effectiveness of Helicobacter pylori eradication therapies due to their anti-inflammatory effect. The aim of this study was to analyze the impact of this therapeutic association in real life. This is a multicenter, prospective, non-interventional study aimed at evaluating the management of H. pylori by European gastroenterologists. Patients were registered in an e-CRF by AEG-REDCap from 2013 to 2020. The association between statin use and H. pylori eradication effectiveness was evaluated through multivariate analysis. Overall, 9988 and 705 patients received empirical and culture-guided treatment, respectively. Overall, statin use was associated with higher effectiveness in the empirical group (OR = 1.3; 95%CI = 1.1-1.5), but no association was found with first-line treatment effectiveness (N = 7738); as an exception, statin use was specifically associated with lower effectiveness of standard triple therapy (OR = 0.76; 95%CI = 0.59-0.99). In the rescue therapy empirical group (N = 2228), statins were associated with higher overall effectiveness (OR = 1.9; 95%CI = 1.4-2.6). However, sub-analyses by treatment schemes only confirmed this association for the single-capsule bismuth quadruple therapy (OR = 2.8; 95%CI = 1.3-5.7). No consistent association was found between statin use and H. pylori therapy effectiveness. Therefore, the addition of statins to the usual H. pylori treatment cannot be currently recommended to improve cure rates.

Comparison between Hybrid, Reverse Hybrid, and Non-Bismuth Levofloxacin Quadruple Regimens for Helicobacter Pylori Infection in Egypt: A Randomized Trial

BACKGROUND The prevalence of Helicobacter pylori (H. pylori) in developing countries is 50.8%, with the highest occurrence presented in Africa (79.1%). It increases the risk of chronic gastritis, peptic ulcer, cancer of the stomach, and lymphoma. The effect of standard treatment for H. pylori eradication is below 80%, and evaluation of alternative lines of treatment is needed. We aimed to compare the hybrid, reverse hybrid, and levofloxacin quadruple therapies as first-line therapy in Egypt. METHODS This was a randomized interventional trial done in the clinics affiliated with the Internal Medicine Department. 330 individuals were selected according to the inclusion criteria. They were divided into three groups: group 1 (110 subjects who received a reverse hybrid regimen), group 2 (110 subjects who received a hybrid regimen), and group 3 (110 subjects who received a non-bismuth levofloxacin quadruple regimen). RESULTS Group 3 had a significantly lower eradication rate of 82.7% versus 92.7% and 91.8% in groups 1 and 2, respectively. There were non-significant differences in the incidence rates of adverse events among the three groups. CONCLUSION Both the reverse hybrid and hybrid groups had good eradication rates in the Egyptian population, but non-bismuth levofloxacin quadruple therapy did not obtain a sufficient eradication rate.

AGA Clinical Practice Update on the Management of Refractory Helicobacter pylori Infection: Expert Review

The purpose of this CPU Expert Review is to provide clinicians with guidance on the management of Helicobacter pylori after an initial attempt at eradication therapy fails, including best practice advice on specific regimen selection, and consideration of patient and systems factors that contribute to treatment efficacy. This Expert Review is not a formal systematic review, but is based upon a review of the literature to provide practical advice. No formal rating of the strength or quality of the evidence was carried out. Accordingly, a combination of available evidence and consensus-based expert opinion were used to develop these best practice advice statements.