You can find out more about NPF's National Medical Director, Dr. Michael S. Okun, by also visiting the NPF Center of Excellence, University of Florida Center for Movement Disorders & Neurorestoration. Dr. Okun is also the author of the Amazon #1 Parkinson's Best Seller 10 Secrets to a Happier Life.
The discovery that a bug in the gut called H. Pylori could underpin gastrointestinal disease and also ulcer formation was one of the most important in modern GI medicine. Why however, would H. Pylori infection be relevant to Parkinson’s disease patients, especially if 2 out of every 3 people on the planet carry the bug in their guts. It turns out that if left untreated H. Pylori may affect the absorption of Parkinson’s disease medications, and consequently affect the overall response to treatment. In this month’s What’s Hot in PD? column we will explore H. Pylori infection and Parkinson’s disease.
Back in 2006 an important paper by Pierantozzi and colleagues was published in the journal Neurology and almost went unnoticed. The researchers based in Rome identified and treated patients with H. Pylori infection, either with an anti-oxidant pill, or with an antibiotic regimen known to eradicate H. Pylori in the gut. The absorption of levodopa in these patients improved, as did the number of hours of “on” time. Later in 2008 in an article by Lee and colleagues from Samsung Medical Center in Korea, these results were verified. The onset of action of levodopa, the “on” duration of the medications, and the Parkinson’s disease scales improved more in the group treated for H. Pylori infection.
Nielsen and colleagues in 2012 examined H. Pylori infection, and the risk of Parkinson’s disease in a study published in the European Journal of Neurology. There were 4484 Danish patients included and they were drawn from the Danish Civil Registration System. The use of H. Pylori eradicating drugs was associated with a 45% increased risk of developing Parkinson’s disease. Similarly, the use of proton pump inhibitors was also associated with a 23% increased risk for the development of Parkinson’s disease. The authors speculated that chronic H. Pylori infections and also gastritis could possibly be related to the risk of developing Parkinson’s disease, though there were many methodological issues limiting the overall study interpretation.
Last week at the International Movement Disorders Society Congress held in Sydney Australia, a group from Malaysia again raised the issue of a relationship between H. Pylori and Parkinson’s disease. There were 27 of 76 Parkinson’s patients in their clinic found to be positive on a breath test that was sensitive for H. Pylori infection. After treatment with oral clarithromycin, amoxicillin, and esomeprazole the onset of action for levodopa improved, and the “on” time also improved. Parkinson’s disease rating scales and questionnaires measuring quality of life also showed positive trends following treatment (unpublished data from the Movement Disorders Society, Ibrahim, et. al. National University of Malaysia).
So, what do patients with Parkinson’s disease and family members need to know about H. Pylori infection? First, the issue as to whether H. Pylori is a risk factor for the later development of Parkinson’s disease remains unknown. Second, if an individual patient is experiencing motor fluctuations that cannot be controlled by medication adjustment this patient should consider asking their primary care doctor (or GI specialist) to check a C-urea breath test for the possible presence of H. Pylori infection. Third, the decision to treat H. Pylori should be made in consultation with the GI specialist and the neurologist, especially since the infection commonly occurs in 2/3 of the population, and the GI specialist may in some cases need to perform follow-up testing (e.g. a scope to visualize the stomach and intestines). Remember also that allergies or tolerability may alter the exact treatment regimen. Finally, motor fluctuations and medication changes should be managed by your neurologist before and after treatment for H. Pylori. It is potentially great news that for some patients with H. Pylori there may be hope for treatment that can improve the response to dopaminergic therapy.
Pierantozzi M, Pietroiusti A, Brusa L, Galati S, Stefani A, Lunardi G, Fedele E, Sancesario G, Bernardi G, Bergamaschi A, Magrini A, Stanzione P, Galante A. Helicobacter pylori eradication and l-dopa absorption in patients with PD and motor fluctuations. Neurology. 2006 Jun 27;66(12):1824-9.
Lee WY, Yoon WT, Shin HY, Jeon SH, Rhee PL. Helicobacter pylori infection and motor fluctuations in patients with Parkinson's disease. Mov Disord. 2008 Sep 15;23(12):1696-700.
Dobbs SM, Dobbs RJ, Weller C, Charlett A, Bjarnason IT, Lawson AJ, Letley D, Harbin L, Price AB, Ibrahim MA, Oxlade NL, Bowthorpe J, Leckstroem D, Smee C, Plant JM, Peterson DW. Differential effect of Helicobacter pylori eradication on time-trends in brady/hypokinesia and rigidity in idiopathic parkinsonism. Helicobacter. 2010 Aug;15(4):279-94.
Nielsen HH, Qiu J, Friis S, Wermuth L, Ritz B. Treatment for Helicobacter pylori infection and risk of Parkinson's disease in Denmark. Eur J Neurol. 2012 Jun;19(6):864-9. doi: 10.1111/j.1468-1331.2011.03643.x. Epub 2012 Jan 17.