First-line therapies for Helicobacter pylori eradication: a critical reappraisal of updated guidelines

Abstract

Helicobacter pylori (H. pylori) treatment remains a challenge for the clinician, as no available therapy is able to cure the infection in all treated patients. In the last two decades, several antibiotic combinations have been proposed, including triple therapies, bismuth-free therapies (sequential, concomitant, hybrid regimens), and bismuth-based quadruple therapy. Some national and international guidelines on H. pylori management have recently been updated, recommending or discouraging the use of each of these therapeutic approaches, based mainly on the presumed pattern of primary antibiotic resistance in different geographic areas. We examined the recommendations on first-line therapies in the most recently updated guidelines worldwide, taking into account other data affecting the efficacy of a therapy regimen beyond the primary resistance pattern. Although several guidelines highlighted that the results achieved by an eradication therapy are population-specific and not directly transferable, it emerged that some therapy regimens are recommended or discouraged with no mention of the vital need for national data.

Correlation of registered drug packs with Maastricht V/Florence Consensus Report and national treatment guidelines for management of Helicobacter pylori infection

“…Furthermore, treatment guidelines for H pylori most often alternate from twice-daily, 7-to 14-day regimens. 31 It comes as no surprise that the results of this study indicate that PPIs are most often prepacked in sizes of 7, 14 or 28 units that is in perfect accordance with a single-daily or twice-daily, 7-or 14-day regimens. This was not found for all of the proposed antimicrobials.…”

“…This may be a challenge especially considering indications for which treatment guidelines differ significantly from season to season. Furthermore, treatment guidelines for H pylori most often alternate from twice‐daily, 7‐ to 14‐day regimens . It comes as no surprise that the results of this study indicate that PPIs are most often prepacked in sizes of 7, 14 or 28 units that is in perfect accordance with a single‐daily or twice‐daily, 7‐ or 14‐day regimens.…”

“…Interestingly, bismuth is proposed in Italian and Slovenian national guidelines prior to registration in Italy and Slovenia . In Croatia, amoxicillin and metronidazole were not matched for 14‐day treatments.…”

“…11 Interestingly, bismuth is proposed in Italian and Slovenian national guidelines prior to registration in Italy and Slovenia. 23,31 In Croatia, amoxicillin and metronidazole were not matched for 14-day treatments. Furthermore, in Slovenia, amoxicillin was not matched with neither national nor European guidelines.…”

Sequential Helicobacter pylori eradication therapy in Myanmar; a randomized clinical trial of efficacy and tolerability

“…Sequential therapy has been proposed as a way to reduce pill load, to increase adherence, to reduce adverse drug effects and, in a low‐income country like Myanmar, to reduce costs . It has been shown to be effective in middle‐ and high‐income Asian countries with studies in Thailand, Singapore and Taiwan, all reporting per‐protocol eradication rates of greater than 90%.…”