PPI Dosage and Duration for H. pylori Eradication Regimens
For H. pylori eradication, standard-dose PPI (such as omeprazole 20mg, lansoprazole 30mg, esomeprazole 20mg, rabeprazole 20mg) should be administered twice daily for 14 days as part of any eradication regimen. 1
PPI Dosing Details
- Standard PPI dosing for H. pylori eradication is twice daily (bid) administration of standard dose PPI (omeprazole 20mg, lansoprazole 30mg, esomeprazole 20mg, rabeprazole 20mg, dexlansoprazole 30mg) 1
- PPI should be taken 30 minutes before meals on an empty stomach for optimal efficacy 1
- Higher-potency PPIs (esomeprazole or rabeprazole) at 40mg twice daily are recommended for improved eradication rates, especially in cases of refractory infection 1
- For patients with refractory H. pylori infection, consider high-dose PPI (double the standard dose) to improve eradication success 1
Duration of Therapy
- 14-day duration is strongly recommended by all major guidelines for all first-line H. pylori eradication regimens 1
- The Toronto Consensus, Maastricht V/Florence Consensus, and American College of Gastroenterology (ACG) all recommend 14 days for PPI triple and hybrid therapies 1
- For bismuth quadruple therapy, 14 days is preferred, though 10 days may be acceptable if proven locally effective 1
- Longer treatment durations (14 days vs 7 days) consistently provide higher eradication success rates 1, 2
PPI Selection Considerations
- Relative potency of PPIs varies significantly: 40mg pantoprazole = 9mg omeprazole; 30mg lansoprazole = 27mg omeprazole; 20mg esomeprazole = 32mg omeprazole; 20mg rabeprazole = 36mg omeprazole 1
- Esomeprazole and rabeprazole (20-40mg bid) are preferred due to their higher potency and less dependence on CYP2C19 metabolism 1, 2
- Pantoprazole should be avoided due to its lower relative potency 1
- For patients with known rapid CYP2C19 metabolism, higher doses of PPI may be necessary 2
Common Pitfalls and Caveats
- Inadequate acid suppression is a common cause of H. pylori eradication failure 1
- Taking PPI with food or other antacids (e.g., H2-receptor antagonists) can reduce effectiveness 1, 3
- Standard triple therapy with PPI is no longer recommended as empiric therapy in most areas due to increasing clarithromycin resistance 2, 4
- PPI-only therapy without antibiotics will not eradicate H. pylori and may worsen gastritis by inducing corpus-predominant pangastritis 5, 6
- In patients who have undergone subtotal gastrectomy, standard-dose PPI may still be necessary despite reduced acid production 7
Algorithm for PPI Selection in H. pylori Eradication
- First-line therapy: Standard-dose esomeprazole or rabeprazole (20mg) twice daily for 14 days 1
- For refractory infection: High-dose esomeprazole or rabeprazole (40mg) twice daily for 14 days 1
- If esomeprazole or rabeprazole unavailable: Lansoprazole 30mg or omeprazole 20mg twice daily for 14 days 1
- Administer PPI 30 minutes before meals on an empty stomach 1