What is the efficacy of triple therapy for Helicobacter pylori (H. pylori) eradication in Asia?

From the Guidelines

Triple therapy for Helicobacter pylori infection in Asia should be tailored based on the local clarithromycin resistance rate, with bismuth quadruple therapy or non-bismuth quadruple therapy recommended in areas with high clarithromycin resistance (>15-20%). The most recent and highest quality study, 1, published in 2020, recommends standard triple therapy (amoxicillin, clarithromycin, and PPI) as first-line therapy if low clarithromycin resistance is present. However, in areas with high clarithromycin resistance, a 10-day sequential therapy with four drugs (amoxicillin, clarithromycin, metronidazole, and PPI) or a non-bismuth quadruple therapy is recommended.

Some key points to consider when prescribing triple therapy for Helicobacter pylori infection in Asia include:

• The choice of treatment regimen should be based on the knowledge of the underlying prevalence of resistant strains in the community 1
• Standard triple therapy (amoxicillin, clarithromycin, and PPI) regimen should be used as first-line therapy if low clarithromycin resistance is present 1
• Sequential therapy with four drugs (amoxicillin, clarithromycin, metronidazole, and PPI) should be considered in selected cases, if compliance to the scheduled regimen can be maintained, and if clarithromycin high resistance is detected 1
• A 10-day levofloxacin-amoxicillin triple therapy is recommended as second-line therapy if first-line therapy failed 1

The effectiveness of triple therapy varies across different Asian countries due to regional variations in antibiotic resistance patterns, with eradication rates ranging from 70-85% 1. Treatment success should be confirmed with a urea breath test, stool antigen test, or endoscopy at least 4 weeks after completing therapy and while off PPI for at least 2 weeks.

In terms of specific treatment regimens, the following are recommended:

• Standard triple therapy: PPI standard dose twice a day, clarithromycin 500 mg twice a day, and amoxicillin 1000 mg twice a day 1
• Sequential therapy: PPI standard dose twice a day, amoxicillin 1000 mg twice a day for the first 5 days, followed by PPI plus clarithromycin 500 mg twice a day and metronidazole 500 mg twice a day for the next 5 days 1
• Levofloxacin-amoxicillin triple therapy: PPI standard dose twice a day, levofloxacin 500 mg once a day or 250 twice a day, and amoxicillin 1000 mg twice a day 1

From the Research

Helicobacter Pylori Treatment in Asia

• The eradication of Helicobacter pylori infection is a significant challenge for physicians, with the prevalence of antibiotic resistance increasing worldwide 2.
• In Asia, the accepted minimal eradication rate of anti-H. pylori regimen in H. pylori-infected patients is 91%, as demonstrated by the Real-world Practice & Expectation of Asia-Pacific Physicians and Patients in Helicobacter Pylori Eradication (REAP-HP) Survey 2.
• The Kyoto Consensus Report on Helicobacter Pylori Gastritis recommends that only regimens which reliably produce eradication rates of ≥90% in a population should be used for empirical treatment 2.

Triple Therapy for Helicobacter Pylori Eradication

• Triple therapy regimens, including two antibiotics plus acid suppression, have become the standard therapy for Helicobacter pylori eradication, with success rates of about 90% 3.
• A study in Asia and Africa found that 1-week triple therapy with omeprazole, amoxicillin, and clarithromycin was efficacious for treating duodenal ulcer disease associated with H. pylori infection, with an eradication rate of 85% by per protocol analysis and 80% by intention-to-treat analysis 4.
• However, the efficacy of triple therapy can be affected by antibiotic resistance, and alternative regimens such as quadruple therapy may be necessary in areas with high resistance rates 2, 5.

Alternative Regimens for Helicobacter Pylori Eradication

• Quadruple therapy regimens, including a proton pump inhibitor, a bismuth salt, metronidazole, and tetracycline, can be effective for H. pylori eradication, especially in cases where triple therapy has failed 5, 6.
• Hybrid or reverse hybrid regimens, which combine different antibiotics and acid suppression, may also be effective for H. pylori eradication, with eradication rates exceeding 90% in some studies 2.