Bismuth Quadruple Therapy Dosages for H. pylori Eradication
The standard bismuth quadruple therapy regimen consists of bismuth subsalicylate 120-140 mg (or 262 mg depending on formulation) 3-4 times daily, tetracycline 500 mg 4 times daily, metronidazole 500 mg 3-4 times daily, and a proton pump inhibitor at standard dose twice daily for 14 days. 1, 2, 3
Complete Regimen Components and Dosing
- Bismuth subsalicylate: 120-140 mg 3-4 times daily or 262 mg (depending on formulation) 2 tablets 3-4 times daily 1, 2, 3
- Tetracycline: 500 mg 4 times daily 1, 3
- Metronidazole: 500 mg 3-4 times daily or 400 mg 4 times daily 1, 2, 3
- Proton pump inhibitor (PPI): Standard dose twice daily 1, 2
- Standard PPI doses: dexlansoprazole 30 mg, esomeprazole 20 mg, lansoprazole 30 mg, omeprazole 20 mg, pantoprazole 40 mg, rabeprazole 20 mg 1
Duration of Treatment
- The recommended duration is 14 days according to Toronto Consensus and Maastricht V/Florence Consensus 1, 2
- American College of Gastroenterology (ACG) considers 10-14 days adequate 1, 2
- 10-day regimens may be acceptable in regions where local efficacy has been demonstrated 2, 4
Modified Dosing Schedules
- Recent evidence supports twice-daily dosing as an alternative to improve adherence:
- This twice-daily regimen has shown comparable efficacy to the standard four-times-daily regimen with eradication rates of 90-95% 5, 6
Important Considerations
- Bismuth quadruple therapy is recommended as first-line treatment in areas with high clarithromycin resistance (>15-20%) 2, 3
- It's also recommended as second-line therapy after failure of clarithromycin-based regimens 1
- The addition of bismuth improves treatment efficacy, especially in the presence of metronidazole resistance 3
- Metronidazole resistance can be partially overcome by increasing the dose and duration of treatment 3
- Doxycycline should not be substituted for tetracycline due to inferior results 3
- For patients with penicillin allergy, bismuth quadruple therapy is preferred over clarithromycin-based regimens 1
Optimizing Treatment Success
- Complete the full course of treatment to maximize eradication rates 2
- Take PPI 30 minutes before eating on an empty stomach 1
- Avoid concomitant use of other antacids such as H2-receptor antagonists 1
- Consider local antibiotic resistance patterns when selecting therapy 2, 3
- After two failed therapies, H. pylori susceptibility testing should be considered 1