Systematic review and meta-analysis: triple therapy combining a proton-pump inhibitor, amoxicillin and metronidazole for<i>Helicobacter pylori</i>first-line treatment

Puig, Ignasi; Ferré, Mireia Baylina; Sánchez-Delgado, Jordi; López-Góngora, Sheila; Suarez, David L.; García-Iglesias, Pilar; Muñoz, Neus; Gisbert, Javier P.; Dacoll, Cristina; Cohen, Henry; Calvet, Xavier

doi:10.1093/jac/dkw220

Cited by 41 publications

(30 citation statements)

References 143 publications

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“…9 A large metaanalysis of more than 90 trials demonstrated an eradication rate of up to 70% with this regimen when used as first-line treatment, which was significantly lower compared with clarithromycin triple therapy with amoxicillin (70% vs 77%, p<0.002) or clarithromycin triple therapy with metronidazole (66% vs 78%, p=0.0003). 56 However, eradication rates for amoxicillin-based triple therapy depend highly on metronidazole resistance rates, and further analysis identified longer treatment durations and higher amoxicillin and metronidazole doses (every 8 hours) as factors closely associated with the improved efficacy of amoxicillin-based triple therapy. When high doses were administered for 14 days, eradication rates for amoxicillin-based triple therapy were similar to first-line treatment regimens.…”

Section: Qtc-interval Prolongationmentioning

confidence: 99%

Treatment of Helicobacter pylori in Special Patient Populations

et al. 2019

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Helicobacter pylori infection can lead to gastritis, gastric and duodenal ulcers, and gastric cancer. Consequently, complete eradication is the goal of therapy. First‐line therapy for H. pylori infection includes clarithromycin triple therapy (clarithromycin, proton pump inhibitor [PPI], and amoxicillin or metronidazole), bismuth quadruple therapy (bismuth salt, PPI, tetracycline, and metronidazole or amoxicillin), or concomitant therapy (clarithromycin, PPI, amoxicillin, and metronidazole). However, many patients have relative contraindications to the antibiotics included in these regimens, making therapy selection difficult. Furthermore, failure of initial therapy makes selection of second‐line therapy challenging due to concerns for potential resistance to agents included in the initial regimen. This review discusses H. pylori microbiology, including antibiotic resistance, and summarizes the existing evidence for first‐ and second‐line treatment regimens that may be considered for special populations such as patients with penicillin allergies, patients with or at risk for QTc‐interval prolongation, and patients who are pregnant, breastfeeding, or elderly.

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Section: Qtc-interval Prolongationmentioning

confidence: 99%

Treatment of Helicobacter pylori in Special Patient Populations

et al. 2019

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“…Puig et al 80 performed a systematic review and meta-analysis to evaluate the efficacy of triple therapy including a PPI, amoxicillin, and metronidazole in areas with moderate-to-high resistance to clarithromycin. Ninety-four studies (7974 patients) were included.…”

Section: A Combined Strategy: Increasing Duration Of Treatment Prementioning

confidence: 99%

“…Although this regimen is, overall, 30% less effective in metronidazole-resistant strains, highdose 14-day schedules partially overcome the resistance effect. 80…”

Section: Regarding Efficacy In Resistant Bacteria In Patients Harboringmentioning

confidence: 99%

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Optimization strategies aimed to increase the efficacy of H. pylori eradication therapies

Gisbert

McNicholl

2017

Helicobacter

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Using potent acid inhibition and/or higher antibiotic doses-especially by increasing the number of daily intakes-and lengthening treatments up to 14 days improves efficacy in most regimens and should be generally recommended. Triple therapies can be efficiently improved by the addition of bismuth salts, turning them into quadruple therapies. Finally, some treatments will require a combination of optimization strategies to significantly improve results.

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“…A high-quality meta-analysis examined the efficacy of triple therapy with amoxicillin and metronidazole which showed that while overall they were less efficacious than clarithromycin-based regimens (70% vs 77%), efficacy was similar when drugs were administered for 14 days (80% vs 84%). 9 An Italian study looked at the effect of PPI dose and found eradication rates improved from 73.9% to 81.9% when double dose (40 mg esomeprazole) twice daily was used compared to standard (20 mg) dosing. 10 In terms of safety, a Japanese study of 322 patient showed a 15% incidence of diarrhea and 2% risk of skin rash.…”

Section: Triple Therapymentioning

confidence: 99%

Treatment of Helicobacter pylori infection 2017

et al. 2017

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Over the last decade, it has been widely reported that the success of Helicobacter pylori eradication treatment is falling. A steady decline was observed in the number of patients achieving eradication with standard first-line triple therapy of two antibiotics and a proton pump inhibitor [1][2][3]. It now appears that the first-line eradication therapies most commonly used in everyday clinical practice fall considerably short of the 80% intention-to-treat (ITT) eradication rates that are considered the minimal acceptable levels as recommended in the Maastricht guidelines [4]. Interestingly, two studies emerged from Asian centers in the last 12 months, which show that, in this part of the world at least, eradication levels using standard therapies remain close to 80%. A Malaysian study showed a standard 1-week pantoprazole, amoxycillin, and clarithromycin regimen to be well tolerated and highly efficacious with a per-protocol eradication rate of 84% [5]. A Japanese study showed remarkably consistent per-protocol eradication rates from 2001 to 2009 fluctuating between 75 and 78% for standard 7-day triple-therapy regimens [6]. A limit of many studies especially those including clarithromycin or levofloxacin is that H. pylori susceptibility to the drugs, which is the main prediction of failure, was not tested. LevofloxacinThe use of levofloxacin as a first-line therapy has been examined in great depth in the last year. Levofloxacin may be used as a substitute for clarithromycin in either a standard triple or sequential regimen. A large study comparing the antibiotics in either regimen shows a clear advantage to levofloxacin in both combinations. Per-protocol cure rates for triple therapy were 66% for omeprazole-clarithromycin-amoxycillin compared with 83% for omeprazole-levofloxacin-amoxycillin and 81% for omeprazole-amoxycillin-clarithromycin-metronidazole vs 85% for omeprazole-amoxycillin-levofloxacinmetronidazole, with no difference in compliance rates or adverse events [7]. It has been proposed that sequential levofloxacin-based regimens are of most benefit in areas where clarithromycin resistance is in excess of 15%, and another study in such an area showed eradication rates of 81% with clarithromycin sequential therapy compared with 96% with levofloxacin sequential therapy. A third arm in this study looked at the dose of levofloxacin required and illustrated no benefit in increasing the dose from 250 to 500 mg [8]. Indeed, another study went so far as to suggest that once-daily dosing of a levofloxacin-based triple regimen may be as efficacious as twice daily [9]. The literature from Asia also seems to support levofloxacin as a good alternative first-line therapy. A study on a triple regimen showed per-protocol eradication rates of 78% for standard clarithromycin-containing therapies compared with 83% for a levofloxacin-based regimen [10]. Another study from the Middle East looked at whether combining clarithromycin and levofloxacin in the same regimen could be Keywords Peptic ulcer disease, resistance, compli...

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Systematic review and meta-analysis: triple therapy combining a proton-pump inhibitor, amoxicillin and metronidazole forHelicobacter pylorifirst-line treatment

Cited by 41 publications

References 143 publications

Treatment of Helicobacter pylori in Special Patient Populations

Treatment of Helicobacter pylori in Special Patient Populations

Optimization strategies aimed to increase the efficacy of H. pylori eradication therapies

Treatment of Helicobacter pylori infection 2017

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