What are the doses and frequencies of medications for Helicobacter pylori (H. pylori) treatment?

Medication Doses and Frequencies for H. pylori Treatment

The standard recommended regimens for H. pylori treatment include bismuth quadruple therapy for 14 days as first-line treatment (bismuth ~300mg qid, metronidazole 500mg tid, tetracycline 500mg qid, PPI bid), with clarithromycin triple therapy and levofloxacin-based regimens as alternatives based on local resistance patterns. 1

First-Line Treatment Options

Bismuth Quadruple Therapy (14 days)

• Bismuth subsalicylate: 300mg (2 tablets/capsules) four times daily, 30 minutes before meals
• Tetracycline HCl: 500mg four times daily, 30 minutes after meals
• Metronidazole: 500mg three times daily
• PPI: Standard dose twice daily, 30 minutes before meals
  • Standard PPI doses: pantoprazole 40mg, lansoprazole 30mg, omeprazole 20mg, esomeprazole 20mg, dexlansoprazole 30mg, rabeprazole 20mg 1

Clarithromycin Triple Therapy (14 days)

• Clarithromycin: 500mg twice daily
• Amoxicillin: 1g twice daily
• PPI: Standard dose twice daily 1, 2

Note: Only use in regions with low clarithromycin resistance (<15%) 1

Concomitant Non-Bismuth Quadruple Therapy (14 days)

• Clarithromycin: 500mg twice daily
• Amoxicillin: 1g twice daily
• Metronidazole/tinidazole: 500mg twice daily
• PPI: Standard dose twice daily 1

Second-Line Treatment Options

Levofloxacin Triple Therapy (14 days)

• Levofloxacin: 500mg once daily in the morning
• Amoxicillin: 1g twice daily
• PPI: Standard dose twice daily 1

Note: FDA recommends fluoroquinolones be used as a last choice due to risk of serious side effects 1

Rifabutin Triple Therapy (10-14 days)

• Rifabutin: 150mg twice daily or 300mg once daily
• Amoxicillin: 1g twice daily
• PPI: Standard dose twice daily 1

High-Dose Dual Therapy (14 days)

• Amoxicillin: 2-3g daily in 3-4 split doses
• PPI: High-dose (double standard dose) twice daily 1

PPI Administration Guidelines

• Optimal PPI dosing: 30 minutes prior to eating on an empty stomach
• Avoid concomitant use of other antacids (e.g., H2 receptor antagonists)
• Higher-potency PPIs recommended: 20-40mg esomeprazole or rabeprazole twice daily 1
• Standard PPI doses: pantoprazole 40mg, lansoprazole 30mg, omeprazole 20mg, esomeprazole 20mg, dexlansoprazole 30mg, rabeprazole 20mg 1

Treatment Selection Algorithm

1. First-line therapy selection:

   • In regions with high clarithromycin resistance (>15%): Bismuth quadruple therapy
   • In regions with low clarithromycin resistance (<15%): Clarithromycin triple therapy

2. After first-line failure:

   • If clarithromycin-based therapy failed: Use bismuth quadruple therapy
   • If bismuth quadruple therapy failed: Use levofloxacin-based therapy

3. After two failed therapies:

   • Perform H. pylori susceptibility testing
   • Choose from: Rifabutin triple therapy, high-dose dual therapy, or levofloxacin quadruple therapy based on susceptibility results 1, 3

Important Clinical Considerations

• Treatment duration of 14 days is recommended for all regimens to improve eradication success 1, 3
• After treatment completion, wait at least 4 weeks before testing for H. pylori eradication 3
• Adjunctive therapies like probiotics are of unproven benefit and should be considered experimental 1
• For H. pylori dosing in dual therapy: 1g amoxicillin and 30mg lansoprazole, all given three times daily for 14 days 2

Common Pitfalls to Avoid

• Using shorter treatment durations (7-10 days) which reduce eradication rates
• Failing to account for local antibiotic resistance patterns
• Not considering patient's prior antibiotic exposure history
• Using outdated regimens like sequential or hybrid therapies that are now considered obsolete 1
• Inadequate PPI dosing or timing (should be taken 30 minutes before meals) 1
• Not waiting sufficient time (4 weeks) after treatment completion before testing for eradication 3