What regimens eradicate Heliobacter pylori?

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Clinical Inquiries

What regimens eradicate Heliobacter pylori?

J Fam Pract. 2003 October;52(10):799-810

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References

1. Current European concepts in the management of Heliobacter pylori infection. The Maastricht Consensus Report. European Heliobacter Pylori Study Group. Gut 1997;41:8-13.

2. Calvet X, Garcia N, Lopez T, Gisbert JP, Gene E, Roque M. A meta-analysis of short versus long therapy with a proton pump inhibitor, clarithromycin and either metronidazole or amoxicillin for treating Heliobacter pylori infection. Aliment Pharmacol Ther 2000;14:603-609.

3. Huang J, Hunt RH. The importance of clarithromycin dose in the management of Heliobacter pylori infection: a meta-analysis of triple therapies with a proton pump inhibitor, clarithromycin, and amoxicillin or metronidazole. Aliment Pharmacol Ther 1999;13:719-729.

4. Janssen MJ, Van Oijen AH, Verbeek AL, Jansen JB, De Boer WA. A systematic comparison of triple therapies for treatment of Heliobacter pylori infection with proton pump inhibitor/ranitidine bismuth citrate plus clarithromycin and either amoxicillin or a nitroimidazole. Aliment Pharmacol Ther 2001;15:613-624.

5. Delaney B, Moayyedi P, Forman D. Heliobacter pylori. Clin Evid [online], Issue 8. London: BMJ Publishing Group, Last updated 2003 March. Available at www.ovid.com. Accessed on March 4, 2003.

6. Treiber G, Wittig J, Ammon S, Walker S, van Doorn LJ, Klotz U. Clinical outcome and influencing factors for a new short-term quadruple therapy for Heliobacter pylori eradication: a randomized controlled trial (MACLOR study). Arch Intern Med. 2002;162:153-160.

7. Wong BC, Wang WH, Wong WM, et al. Three-day lansoprazole quadruple therapy for Heliobacter pylori-positive duodenal ulcers: a randomized controlled study. Aliment PharmacTher 2001;15:843-849.

8. Howden CW, Hunt RH. Guidelines for the management of Heliobacter pylori infection. Ad Hoc Committee on the Practice Parameters of the American College of Gastroenterology. Am J Gastroenterol 1998;93:2330-2338.

9. Institute for Clinical Systems Improvement (ICSI). Dyspepsia. Bloomington, Minn: ICSI; last updated January 2003. Available at: http://www.icsi.org/ knowledge/detail.asp?catID=29&itemID=171. Accessed on September 8, 2003.

Recommendations from others

The Maastricht Consensus of the European Heliobacter Study Group¹ recommends a 7-day triple regimen of PPI + clarithromycin + either metronidazole or amoxicillin or (if clarithromycin resistance is prevalent) PPI + amoxicillin 500 mg 3 times daily + metronidazole 500 mg 3 times daily.

The American College of Gastroenterology recommends 14-day therapy of one of the following options:⁸

PPI + clarithromycin + (metronidazole or amoxicillin), or ranitidine bismuth citrate + clarithromycin + (metronidazole or amoxicillin). Tetracycline 500 mg twice a day can be substituted for amoxicillin or metronidazole
PPI + bismuth subsalicylate 525 mg + metronidazole 500 mg 3 times daily + tetra-cycline 500 mg 4 times daily
Bismuth subsalicylate 525 mg 4 times daily + metronidazole 250 mg 4 times daily + tetra-cycline 500 mg 4 times daily + H2 receptor antagonist in standard acid-suppression dose (eg, famotidine 20 mg twice a day for 4 weeks).

The Institute for Clinical Systems Improvement recommends as first-choice treatment a 7-day PPI/clarithromycin/amoxicillin combination, and as second choice a 7-day regimen of PPI, tetracycline 250 mg 4 times daily, metronidazole 500 mg twice daily, and bismuth subsalicylate 525 mg 4 times daily.⁹

CLINICAL COMMENTARY

Patients beginning complex regimens require counseling
Laura B. Hansen, PharmD, BCPS
University of Colorado Health Sciences Center, Denver, Colorado

The most effective regimens (>80% eradication) for H pylori include a 10- to 14-day course of at least 2 antibiotics and an antisecretory agent. However, even optimal treatment regimens can fail in approximately 10% of patients. Poor compliance is among the most common reasons for treatment failure. Medication side effects can affect up to 50% of patients taking triple-agent regimens.

Treatment regimens with multiple medications administered several times daily can be difficult to follow. Convenient packaging containing all daily medications are available to optimize adherence.

Counseling points for patients should include how to take the medicine correctly, expected side effects, the importance of completing the entire therapy regimen, and warnings of specific interactions (eg, alcohol and metronidazole). Lastly, the patient should be made aware of the cost of the entire regimen, which ranges from $50 to $250.

Evidence-based answers from the Family Physicians Inquiries Network

What regimens eradicate Heliobacter pylori?

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