From the Guidelines
The most effective treatment for H. pylori infection is a combination therapy approach, with the first-line treatment typically consisting of a proton pump inhibitor (PPI) such as omeprazole 20mg twice daily, combined with two antibiotics—amoxicillin 1g twice daily and clarithromycin 500mg twice daily—for 14 days, as recommended by the most recent study 1.
Key Considerations
- The choice of treatment regimen should be based on the knowledge of the underlying prevalence of resistant strains in the community, as stated in the study 1.
- Increasing antibiotic resistance has made treatment more challenging, so adherence to the full course of therapy is crucial for successful eradication, as highlighted in the study 1.
- If the first-line therapy fails, quadruple therapy or levofloxacin-based triple therapy may be considered as second-line options, as suggested in the study 1.
Treatment Options
- First-line therapy: PPI (e.g. omeprazole 20mg twice daily) + amoxicillin 1g twice daily + clarithromycin 500mg twice daily for 14 days, as recommended by the study 1.
- Second-line therapy:
- Quadruple therapy: PPI + bismuth subsalicylate 525mg four times daily + tetracycline 500mg four times daily + metronidazole 250mg four times daily for 10-14 days, as suggested in the study 1.
- Levofloxacin-based triple therapy: PPI + amoxicillin 1g twice daily + levofloxacin 500mg once daily for 10-14 days, as recommended by the study 1.
Important Notes
- Confirmation of eradication should be performed at least 4 weeks after completing therapy, using either a urea breath test, stool antigen test, or endoscopic biopsy, as stated in the study 1.
- Treatment is important because H. pylori causes chronic gastritis and is associated with peptic ulcer disease, gastric cancer, and MALT lymphoma, as highlighted in the study 1.
From the FDA Drug Label
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. Dual therapy for H. pylori with lansoprazole : Amoxicillin, in combination with lansoprazole delayed-release capsules as dual 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) who are either allergic or intolerant to clarithromycin or in whom resistance to clarithromycin is known or suspected.
Treatment of H. pylori involves the use of amoxicillin in combination with other medications. The recommended treatments are:
- Triple therapy: amoxicillin, clarithromycin, and lansoprazole
- Dual therapy: amoxicillin and lansoprazole, for patients who are allergic or intolerant to clarithromycin, or in whom resistance to clarithromycin is known or suspected 2
From the Research
Treatment Options for H. pylori
- The standard triple therapy for H. pylori eradication includes a proton pump inhibitor, clarithromycin, and amoxicillin, but it may not be effective in areas with high clarithromycin resistance 3.
- A quadruple therapy regimen consisting of omeprazole, metronidazole, clarithromycin, and amoxicillin has been shown to be effective in eradicating H. pylori, with eradication rates of 96% and 92% in patients without and with previous dual therapy, respectively 4.
- Levofloxacin-based rescue therapy has been found to be an effective third-line strategy after multiple previous H. pylori eradication failures, with per-protocol and intention-to-treat eradication rates of 66% and 60%, respectively 5.
Duration and Efficacy of Treatment
- A 14-day regimen of high-dose proton pump inhibitor triple therapy has been shown to provide an excellent cure rate of 100%, regardless of the CYP2C19 genotype 3.
- A 7-day regimen of triple therapy with omeprazole, clarithromycin, and amoxicillin has been found to have an eradication rate of 89.6%, while a 2-week regimen has an eradication rate of 95.7% 6.
Diagnostic and Management Strategies
- The "test-and-treat" strategy is recommended for managing H. pylori infection, with the choice of testing method based on patient age, presenting symptoms, and medication use, as well as test reliability, availability, and cost 7.
- Care must be taken to ensure that therapy is selected based on regional resistance patterns and prior antibiotic exposure, with bismuth quadruple therapy, levofloxacin-based, or alternative macrolide-containing therapies considered as options 7.