What is the recommended medication regimen for the treatment of Helicobacter pylori (H. pylori)?

From the Guidelines

The recommended first-line treatment for Helicobacter pylori infection is typically a 14-day quadruple therapy regimen consisting of a proton pump inhibitor (PPI) such as omeprazole 20mg twice daily, bismuth subsalicylate 525mg four times daily, tetracycline 500mg four times daily, and metronidazole 500mg three times daily, as supported by the most recent and highest quality study 1. This regimen is favored due to its high efficacy and ability to overcome potential antibiotic resistance. Alternative first-line options include clarithromycin-based triple therapy (PPI, clarithromycin 500mg, and amoxicillin 1g, all twice daily for 14 days) in regions with low clarithromycin resistance, or non-bismuth quadruple therapy (concomitant therapy) consisting of a PPI, amoxicillin, clarithromycin, and metronidazole, all twice daily for 10-14 days. Some key points to consider when treating H. pylori infection include:

• Treatment success should be confirmed with a urea breath test, stool antigen test, or endoscopic biopsy at least 4 weeks after completing therapy and after PPI discontinuation for at least 2 weeks 1.
• Antibiotic resistance is a growing concern, so treatment regimens may need to be adjusted based on local resistance patterns or after failed initial therapy 1.
• Patients should be advised to take the full course of antibiotics even if symptoms improve and to avoid alcohol during treatment with metronidazole due to potential disulfiram-like reactions.
• The eradication of H. pylori is important as it can prevent recurrence of peptic ulcers and reduce the risk of gastric cancer in susceptible individuals. It's also important to note that the choice of therapy should consider effectiveness and cost of various regimens versus side effects, and that surveillance registries for H. pylori resistance and local therapy success rates should be mandatory to guide treatment decisions 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. The recommended medication regimen for the treatment of Helicobacter pylori (H. pylori) is:

• Triple therapy: 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily for 14 days.
• Dual therapy: 1 gram amoxicillin and 30 mg lansoprazole, all given three times daily for 14 days 2 2.

From the Research

Medication Regimens for H. pylori Treatment

The recommended medication regimens for the treatment of Helicobacter pylori (H. pylori) infection include:

• Concomitant nonbismuth quadruple therapy (proton pump inhibitor [PPI] + amoxicillin + metronidazole + clarithromycin [PAMC]) 3
• Traditional bismuth quadruple therapy (PPI + bismuth + metronidazole + tetracycline [PBMT]) 3
• PPI triple therapy (PPI + clarithromycin + either amoxicillin or metronidazole), restricted to areas with known low clarithromycin resistance or high eradication success with these regimens 3
• Quadruple therapy with amoxicillin, clarithromycin, tinidazole, and omeprazole, taken twice daily for 4 days 4
• A combination formulation of bismuth, metronidazole, and tetracycline with omeprazole, taken for 10 days 5
• Amoxicillin/metronidazole/omeprazole/clarithromycin, a new short quadruple therapy for H. pylori eradication, taken for 5 days 6
• Metronidazole, omeprazole, and clarithromycin, an effective combination therapy for H. pylori infection, taken for 2 weeks 7

Key Considerations

• The choice of medication regimen should take into account local antibiotic resistance and eradication patterns 3
• All treatments should be given for 14 days, as recommended by the Toronto Consensus for the Treatment of Helicobacter pylori Infection in Adults 3
• Rescue therapies, such as PBMT and levofloxacin-containing therapy, should be considered for patients who have failed previous treatments 3
• Rifabutin regimens should be restricted to patients who have failed to respond to at least 3 prior options 3