Helicobacter pylori infection medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Medical Therapy

First-Line Regimens for Helicobacter pylori Eradication

• Bismuth quadruple therapy has been advocated as a primary therapy for H.pylori.
• In patients who have not previously received clarithromycin and who are not allergic to penicillin, PPI, clarithromycin, and amixicillin are considered.
• For patients allergic to penicillin, metronidazole is given as an alternative for amoxicillin.
• In patients who are allergic to penicillin or those who have previously been treated with a macrolide antibiotic, bismuth quadraple therapy is considered.

Regimen	Duration	Eradication rates	Comments
Standard dose PPI b.i.d. (esomeprazole is q.d.), clarithromycin 500 mg b.i.d., amoxicillin 1,000 mg b.i.d.	10–14	70–85%	Consider in nonpenicillin allergic patients who have not previously received a macrolide
Standard dose PPI b.i.d., clarithromycin 500 mg b.i.d. metronidazole 500 mg b.i.d.	10–14	70–85%	Consider in penicillin allergic patients who have not previously received a macrolide or are unable to tolerate bismuth quadruple therapy
Bismuth subsalicylate 525 mg p.o. q.i.d. metronidazole 250 mg p.o. q.i.d., tetracycline 500 mg p.o. q.i.d., ranitidine 150 mg p.o. b.i.d. or standard dose PPI q.d. to b.i.d.	10–14	75–90%	Consider in penicillin allergic patients
PPI + amoxicillin 1 g b.i.d. followed by PPI, clarithromycin 500 mg, tinidazole 500 mg b.i.d.	5 5	>90%	Requires validation in North America
PPI = proton pump inhibitor; pcn = penicillin; p.o. = orally; q.d. = daily; b.i.d. = twice daily; t.i.d. = three times daily; q.i.d. = four times daily. *Standard dosages for PPIs are as follows: lansoprazole 30 mg p.o., omeprazole 20 mg p.o., pantoprazole 40 mg p.o., rabeprazole 20 mg p.o., esomeprazole 40 mg p.o. Note: the above recommended treatments are not all FDA approved.

FDA approved regimens are as follows:

1. Bismuth 525 mg q.i.d. + metronidazole 250 mg q.i.d. + tetracycline 500 mg q.i.d. × 2 wk + H2RA as directed × 4 wk.

2. Lansoprazole 30 mg b.i.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 10 days.

3. Omeprazole 20 mg b.i.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 10 days.

4. esomeprazole 40 mg q.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 10 days.

5. Rabeprazole 20 mg b.i.d. + clarithromycin 500 mg b.i.d. + amoxicillin 1 g b.i.d. × 7 days.

Predictors of H.pylori Treatment Outcome

Predictors of treatment failure include:

• Poor compliance
• Antibiotic resistance
• Bacterial factors like CagA-negative strains are at increased risk of treatment failure compared with CagA-positive strains
• CYP2C 19 polymorphisms may influence treatment outcomes when regimens containing PPIs are used as they influence the clearance of PPIs and thus their effect on gastric acid secretion.

Drugs	Side effects	Recommendations
Proton pump inhibitors (PPIs)	Headache Diarrhea	PPIs should be taken 30-60 min before eating to optimize their effects on gastric acid secretion.
Clarithromycin	GI upset Headache Altered taste
Amoxicillin	GI upset Headache Diarrhea
Metronidazole	Metallic taste in the mouth Dyspepsia A disulfuram like reaction with alcohol consumption
Tetracycline	GI upset Photosensitivity	Tetracyclinhes should not be given to children under 8 yr of age because of possible tooth discoloration
Bismuth Compounds	Darkening of tongue and stool Nausea GI upset