What is the recommended triple therapy regimen for Helicobacter pylori (H. pylori) treatment?

Recommended Triple Therapy for H. pylori Infection

The recommended first-line triple therapy for H. pylori eradication is 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily for 14 days. 1

First-Line Treatment Options

Standard Triple Therapy

• Composition:
  • Amoxicillin: 1 gram twice daily
  • Clarithromycin: 500 mg twice daily
  • Proton pump inhibitor (PPI): Lansoprazole 30 mg twice daily
• Duration: 14 days
• Administration: Take at the start of a meal to minimize gastrointestinal intolerance 1
• Expected eradication rate: Approximately 85% when used for full 14-day course 2

Alternative Triple Therapy Considerations

• Higher-potency PPIs (esomeprazole or rabeprazole 40 mg twice daily) may improve eradication rates 2
• Double-dose PPI (such as esomeprazole 40 mg twice daily) has shown slightly better eradication rates compared to standard dose (81.9% vs 73.9%), though the difference was not statistically significant 3

Bismuth Quadruple Therapy

Due to increasing clarithromycin resistance, bismuth quadruple therapy is now often preferred as first-line treatment when antibiotic susceptibility is unknown:

• Composition:
  • Bismuth subsalicylate
  • Tetracycline HCl
  • Metronidazole
  • PPI
• Duration: 14 days
• Expected eradication rate: 85-90% 2
• Note: The American College of Gastroenterology now recommends bismuth quadruple therapy for 14 days as the preferred regimen when antibiotic susceptibility is unknown 4

Follow-up Testing and Patient Education

• Test for eradication at least 4 weeks after completing treatment 2
• Stop PPI at least 2 weeks before testing 2
• Use either urea breath test or monoclonal stool antigen test for confirmation 2
• Patient counseling is essential:
  • Inform about potential side effects
  • Emphasize the importance of completing the full course of treatment
  • Advise avoiding alcohol while taking metronidazole if part of the regimen 2

Special Considerations

• Penicillin allergy: Avoid amoxicillin-containing regimens if penicillin allergy is confirmed 2
• Renal impairment: Patients with GFR less than 30 mL/min should NOT receive the 875 mg dose of amoxicillin; adjust dosing according to severity of renal impairment 1
• Treatment failure: After first-line therapy failure, avoid previously used antibiotics when possible 2
• Dual therapy option: An alternative is dual therapy with 1 gram amoxicillin and 30 mg lansoprazole, each given three times daily for 14 days 1

Common Pitfalls to Avoid

1. Inadequate treatment duration: 14-day regimens are recommended to maximize eradication rates 2
2. Poor patient compliance: Thoroughly educate patients about the importance of completing the full course of antibiotics
3. Testing too soon after treatment: Wait at least 4 weeks after completing therapy before testing for eradication
4. Not stopping PPI before testing: PPIs should be discontinued at least 2 weeks before follow-up testing to avoid false negatives
5. Using clarithromycin in areas with high resistance: In regions with high clarithromycin resistance, bismuth quadruple therapy may be more appropriate as first-line treatment

The 14-day triple therapy with amoxicillin, clarithromycin, and a PPI remains a standard approach for first-line H. pylori eradication, though bismuth quadruple therapy is increasingly preferred due to rising antibiotic resistance patterns.