Update on therapeutic options for Helicobacter pylori-related diseases

Abstract

Triple therapy including clarithromycin, amoxicillin, and a proton pump inhibitor (PPI) has been recommended as the treatment of choice for Helicobacter pylori eradication. This regimen is now challenged by an increasing level of clarithromycin resistance that jeopardizes the treatment success. When clarithromycin resistance has been detected, or when its rate is known to be high in the geographic area, this drug cannot be used. It can be replaced by metronidazole, the resistance of which has a limited clinical relevance. Another option is to prescribe tetracycline and metronidazole with a PPI or ranitidine bismuth citrate. New antibiotics such as levofloxacin or rifabutin can also be used in combination with amoxicillin and a PPI. Probiotics can be added to all of these regimens to improve compliance by decreasing adverse events. But some authors advocate a quadruple therapy as a first-line treatment. Solutions to improve the limitations of this last regimen are now being proposed. Clarification of the controversial treatment indications such as gastroesophageal reflux disease or prevention of nonsteroidal anti-inflammatory drug gastroduodenal symptoms has been made. The question of prevention of gastric carcinoma by H. pylori eradication remains unanswered.

Helicobacter pylori eradication: A randomised comparative trial of 7-day versus 14-day triple therapy

“…11 Our results are consistent with recent studies such as the HYPER study 12 from Italy, which was a large, multicentre, double-blind and randomised study comparing the efficacy of 1-and 2-week regimens of omeprazole, amoxicillin and clarithromycin. Their ITT (N=907) and PP (N=661) analyses showed no significant differences between the eradication rates at 1 week (ITT 79.7%; PP 83.6%) and 2 weeks (ITT 81.7%; PP 84.9%) (ITT p=0.53; PP p=0.71).…”

Current concepts in the management of Helicobacter pylori infection: the Maastricht III Consensus Report

“…69 Based on these data, the predicted eradication rates for the PPI-clarithromycin-metronidazole combination show a better efficacy than PPI-clarithromycin-amoxicillin, which is nullified only when metronidazole resistance reaches 40%. 70 A 14 day treatment led to a 12% (95% confidence interval 7 to 17%) higher eradication rate based on a single meta-analysis. 71 Few studies have compared the cost effectiveness of these different strategies.…”

“…72 Numerous studies with PPI triple therapy for seven days, mainly from European countries, confirm that this is still a valid duration for this treatment. 70 Bismuth-containing quadruple therapy (10 or 14 days) is an option for the first line treatment. It leads to satisfactory eradication rates despite the increased resistance to both clarithromycin and metronidazole.…”

Prevalencia de la resistencia a metrodinazol, claritromicina y tetraciclina en Helicobacter pylori aislado de pacientes de la Región Metropolitana

“…Sin embargo, el estudio de riesgo para Cla no presentó un patrón definido de resistencia (Tabla 2). La alta resistencia observada a Cla es un dato de gran importancia, ya que en la toma de decisión, para definir un tratamiento que incluya la Cla en las regiones en que la resistencia es alta, se sugiere que este antibiótico sea reemplazado por Mtz, ya que se estima que la resistencia a Mtz tendría una relevancia clínica limitada 35 .…”