What is the role of Pesto (possibly referring to a proton pump inhibitor, PPI) tablets in Helicobacter pylori (H. pylori) quadruple therapy?

From the Guidelines

Pesto tablets are not a recognized medication for Helicobacter pylori (H. pylori) treatment, and quadruple therapy is the recommended treatment approach. For H. pylori eradication, quadruple therapy typically consists of a proton pump inhibitor (PPI) such as omeprazole 20mg twice daily, bismuth subsalicylate 525mg four times daily, tetracycline 500mg four times daily, and metronidazole 500mg three times daily, all taken for 10-14 days 1. This regimen is particularly useful in areas with high clarithromycin resistance or for patients who have failed previous treatment attempts.

Key Considerations

• The choice of treatment regimen should be based on the knowledge of the underlying prevalence of resistant strains in the community 1.
• In areas with low clarithromycin resistance, clarithromycin-containing treatments are recommended for first-line empirical treatment 1.
• Alternative quadruple therapies include concomitant therapy (PPI, amoxicillin, clarithromycin, and metronidazole) or sequential therapy 1.
• Patients should complete the entire course of treatment even if symptoms improve, avoid alcohol during treatment due to potential interactions with metronidazole, and undergo follow-up testing at least 4 weeks after completing therapy to confirm eradication.

Treatment Regimens

• Bismuth quadruple therapy with a duration of 14 days is recommended for populations with high metronidazole resistance 1.
• Metronidazole-containing triple therapy is preferred for populations with low metronidazole resistance due to its effectiveness, fewer side effects, and lower cost 1.
• The optimal doses and durations of bismuth quadruple therapy in the presence of metronidazole resistance are unknown, but 14-day therapy is consistent with current evidence 1.

Side Effects and Follow-up

• Side effects may include nausea, metallic taste, darkened stools, and temporary tongue discoloration.
• Follow-up testing should be done at least 4 weeks after completing therapy to confirm eradication 1.

From the FDA Drug Label

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. In the triple therapy clinical trials, 84. 9% (157/185) of the patients in the omeprazole/clarithromycin/amoxicillin treatment group who had pretreatment amoxicillin susceptible MICs (≤ 0.25 mcg/mL) were eradicated of H. pylori and 15. 1% (28/185) failed therapy.

Pesto tablets are not mentioned in the provided drug labels. The labels discuss the use of omeprazole, clarithromycin, and amoxicillin for the treatment of H. pylori infection.

• The triple therapy regimen of omeprazole, clarithromycin, and amoxicillin is effective in eradicating H. pylori in approximately 84.9% of patients 2.
• The dosage and administration of amoxicillin for H. pylori infection is provided in the amoxicillin drug label 3.

From the Research

Pesto Tablets with H. Pylori Quadruple Therapy

• The use of quadruple therapy for H. pylori eradication has been studied in several research papers 4, 5, 6, 7, 8.
• A study published in 1998 found that a 5-day quadruple therapy regimen consisting of omeprazole, metronidazole, clarithromycin, and amoxicillin was effective and safe for H. pylori eradication 4.
• The American Journal of Gastroenterology published a guideline in 2017 recommending bismuth quadruple therapy or concomitant therapy as first-line treatment for H. pylori infection 5.
• A randomized controlled trial published in 2010 compared the efficacy and safety of two quadruple therapy regimens for second-line treatment of H. pylori infection, and found that a regimen consisting of azithromycin, ofloxacin, bismuth, and omeprazole was more effective than a regimen consisting of amoxicillin, clarithromycin, bismuth, and omeprazole 6.
• A review article published in 2020 discussed the current diagnostic and management strategies for H. pylori infection, and recommended considering bismuth quadruple therapy as a first-line treatment option 7.
• A study published in 2012 compared the efficacy and tolerability of two first-line H. pylori eradication regimens, and found that a regimen consisting of omeprazole, metronidazole, and amoxicillin was more effective than a regimen consisting of lansoprazole, clarithromycin, and amoxicillin 8.

Key Findings

• Quadruple therapy regimens have been shown to be effective and safe for H. pylori eradication 4, 6.
• The choice of treatment regimen should be based on regional resistance patterns and prior antibiotic exposure 5, 7.
• Bismuth quadruple therapy is a recommended first-line treatment option for H. pylori infection 5, 7.
• The efficacy and tolerability of different quadruple therapy regimens can vary 6, 8.