From the Guidelines
For patients who cannot tolerate tetracycline in H. pylori treatment, the most effective alternative regimen is bismuth quadruple therapy substituting amoxicillin for tetracycline, as recommended by the most recent guidelines 1.
Treatment Options
The treatment options for H. pylori infection in patients who do not tolerate tetracycline include:
- Bismuth quadruple therapy substituting amoxicillin for tetracycline (bismuth subsalicylate 525mg QID, metronidazole 500mg TID, amoxicillin 1g BID, and a PPI BID for 14 days) 1
- Clarithromycin-based triple therapy consisting of a PPI (such as omeprazole 20mg BID), amoxicillin 1g BID, and clarithromycin 500mg BID for 14 days, though this is less effective in areas with high clarithromycin resistance 1
- Levofloxacin-based triple therapy using a PPI BID, amoxicillin 1g BID, and levofloxacin 500mg daily for 10-14 days 1
Considerations
When selecting a treatment regimen, it is essential to consider local antibiotic resistance patterns, patient's medication history, and allergies 1.
Eradication Confirmation
Eradication should be confirmed with a urea breath test, stool antigen test, or endoscopic biopsy at least 4 weeks after completing therapy and after stopping PPI for at least 2 weeks 1.
Resistance Patterns
The rising rates of levofloxacin resistance should be taken into account when selecting a treatment regimen 1, and individual susceptibility testing is generally only advised after second-line treatment failure 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.
For patients who do not tolerate tetracycline, the treatment options for Helicobacter pylori (H. pylori) infection are:
- Dual therapy: Amoxicillin in combination with lansoprazole
- Triple therapy is not an option if the patient is intolerant to clarithromycin or tetracycline is not mentioned as an alternative, however amoxicillin and lansoprazole can be used as a dual therapy option as mentioned above. 2 3
From the Research
Treatment Options for H. pyli Infection
In patients who do not tolerate tetracycline, several alternative treatment options are available for Helicobacter pyli (H. pyli) infection.
- First-line treatment: A combination of a proton-pump inhibitor, clarithromycin, and metronidazole can be used as a first-line treatment for H. pyli infection in patients allergic to penicillin 4.
- Rescue options: For patients who have failed first-line treatment, rescue options may include a regimen with ranitidine bismuth citrate, metronidazole, and a substitute for tetracycline, or a levofloxacin-based regimen with a proton-pump inhibitor and clarithromycin 4.
- Alternative therapies: Although amoxicillin and tetracycline combinations are not recommended due to low eradication rates 5, other alternative therapies such as a combination of a high-dose proton-pump inhibitor, amoxicillin, and doxycycline have been studied, but were found to be ineffective for H. pyli eradication 6.
- Optimal treatment regimens: Optimal first-line and second-line treatment regimens for H. pyli infection have been identified, including 14-day therapies with clarithromycin-amoxicillin-bismhol and metronidazole-tetracycline-bismhol, and levofloxacin-amoxicillin triple therapy for 14 days with high-dose proton-pump inhibitor 7. However, these regimens may need to be modified for patients who do not tolerate tetracycline.