What is the appropriate therapy for Helicobacter pylori (H. pylori) infection?

From the Guidelines

Helicobacter pylori infection should be treated with a standard triple therapy regimen consisting of a proton pump inhibitor (PPI), amoxicillin, and clarithromycin, as first-line therapy if low clarithromycin resistance is present 1. This recommendation is based on moderate-quality evidence and is supported by several international guidelines. The suggested doses are:

• PPI standard dose twice a day;
• Clarithromycin 500 mg twice a day;
• Amoxicillin 1000 mg twice a day. In cases where clarithromycin high resistance is detected, a 10-day sequential therapy with four drugs (amoxicillin, clarithromycin, metronidazole, and PPI) can be considered, with recommended doses of:
• PPI standard dose twice a day;
• Amoxicillin 1000 mg twice a day;
• Clarithromycin 500 mg twice a day;
• Metronidazole 500 mg twice a day. If first-line therapy fails, a 10-day levofloxacin-amoxicillin triple therapy can be used as second-line therapy, with suggested doses of:
• PPI standard dose twice a day;
• Levofloxacin 500 mg once a day or 250 twice a day;
• Amoxicillin 1000 mg twice a day. It is essential to note that the choice of treatment regimen should be based on the knowledge of the underlying prevalence of resistant strains in the community, as the response to eradication therapy is significantly related to the prevalence of primary resistance in the population 1.

Some key points to consider when treating H. pylori infection include:

• The importance of acid suppression with PPIs as an essential component of effective treatment regimens
• The need to confirm eradication at least 4 weeks after therapy completion using either urea breath test, stool antigen test, or endoscopic biopsy
• The association of H. pylori with chronic gastritis, peptic ulcer disease, gastric cancer, and MALT lymphoma, making treatment crucial for preventing these complications. Overall, the treatment of H. pylori infection requires careful consideration of the patient's specific situation, including the presence of resistant strains and the potential for treatment failure, in order to provide the most effective therapy and prevent long-term complications 1.

From the FDA Drug Label

Dosing for H. pylori Infection (in Adults): Triple therapy: 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily (every 12 hours) for 14 days. Dual therapy: 1 gram amoxicillin and 30 mg lansoprazole, all given three times daily (every 8 hours) for 14 days. Adult Patients only Helicobacter pylori Infection and Duodenal Ulcer Disease: Triple therapy for Helicobacter pylori (H. pylori) with clarithromycin and lansoprazole : Amoxicillin, in combination with clarithromycin plus lansoprazole as triple therapy, is indicated for the treatment of patients with H pylori infection and duodenal ulcer disease (active or 1-year history of a duodenal ulcer) to eradicate H. pylori.

H. pylori Therapy:

• The recommended dosing for H. pylori infection in adults is either triple therapy or dual therapy.
• Triple Therapy: 1 gram of amoxicillin, 500 mg of clarithromycin, and 30 mg of lansoprazole, all given twice daily for 14 days.
• Dual Therapy: 1 gram of amoxicillin and 30 mg of lansoprazole, all given three times daily for 14 days. 2 2

From the Research

H pylori Therapy Overview

• The standard triple therapy for Helicobacter pylori eradication is no longer effective as an empiric choice in most areas 3.
• A 14-day high-dose proton pump inhibitor (PPI) triple therapy consisting of lansoprazole, amoxicillin, and long-acting clarithromycin provided an excellent cure rate (100%) regardless of the CYP2C19 genotype 3.

First-Line Treatment Options

• In regions with low (≦15%) clarithromycin resistance, 14-day hybrid, 10-14-day sequential, 7-14-day concomitant, 10-14-day bismuth quadruple, or 14-day triple therapy can achieve a high eradication rate in the first-line treatment of H. pylori infection 4.
• In areas with high (>15%) clarithromycin resistance, standard triple therapy should be abandoned, and 14-day hybrid, 10-14-day concomitant, or 10-14-day bismuth quadruple therapy are recommended regimens 4.
• Bismuth quadruple therapy and nonbismuth quadruple therapies (sequential, concomitant, and sequential-concomitant hybrid) are some first-line regimen options in regions suspected to have high clarithromycin resistance 5.

Comparison of Treatment Regimens

• A study compared the efficacy and tolerability of proton pump inhibitor-amoxicillin-clarithromycin versus proton pump inhibitor-amoxicillin-metronidazole as first-line H. pylori eradication therapy, and found that the latter regimen was significantly more effective 6.
• A 5-day regimen of lansoprazole, clarithromycin, and metronidazole (LCM) or clarithromycin, amoxicillin, and metronidazole (CALM) yielded acceptable eradication rates, with LCM and CALM giving significantly better eradication rates than lansoprazole, amoxicillin, and clarithromycin (LAC) 7.