Medline ® Abstracts for References 1-5
of 'Treatment regimens for Helicobacter pylori'
Rifabutin- and furazolidone-based Helicobacter pylori eradication therapies after failure of standard first- and second-line eradication attempts in dyspepsia patients.
Qasim A, Sebastian S, Thornton O, Dobson M, McLoughlin R, Buckley M, O'Connor H, O'Morain C
Aliment Pharmacol Ther. 2005;21(1):91.
BACKGROUND: Optimal management approach is not well defined for subjects who fail initial first- and second-line Helicobacter pylori eradication attempts and are dealt on a case-by-case basis by the specialists.
AIM: To evaluate the efficacy and safety of standard and 'rescue' eradication therapies at primary and secondary care levels.
METHODS: H. pylori infected dyspepsia patients referred to our C13 urea breath testing laboratory between January 1999 to February 2002 were included. Eradication failure at secondary care level was treated using strategies including antibiotic sensitivity testing and the use of rifabutin- and furazolidone-based therapies.
RESULTS: 3280 patients received standard first-line eradication therapy, which was successful in 2530 (77%) patients. Second-line therapy (bismuth-based 'quadruple') or triple therapy (altering constituent antibiotics) was successful in 56% of 270 treated patients. Subsequent eradication attempts using rifabutin-based (n = 34) and furazolidone-based (n = 10) regimens were successful in 38% and 60% patients respectively. H. pylori eradication rates were significantly different for guidelines compliant (94.8%) and non-compliant (82%) groups (P = 0.0001). H. pylori eradication rates for non-ulcer dyspepsia (40%) and peptic ulcer disease (36%) were not significantly different.
CONCLUSIONS: Available H. pylori eradication therapies remain very effective and compliance to guidelines achieves high success rates. Furazolidone-based 'rescue' regimen achieved high eradication rates after failure of the standard first-line, second-line and rifabutin-based therapies.
Gastroenterology Department, Adelaide and Meath Hospital, Tallaght, Dublin, Ireland.
A 10-day levofloxacin-based triple therapy in patients who have failed two eradication courses.
Gatta L, Zullo A, Perna F, Ricci C, De Francesco V, Tampieri A, Bernabucci V, Cavina M, Hassan C, Ierardi E, Morini S, Vaira D
Aliment Pharmacol Ther. 2005;22(1):45.
BACKGROUND: A standard third-line treatment is lacking, and European guidelines recommend performing culture in these patients. However, the use of this procedure as 'routine practice' is definitively not feasible.
AIM: To evaluate the eradication rate of a 10-day levofloxacin-based triple therapy in patients who have failed two eradication courses for Helicobacter pylori.
METHODS: A total of 151 patients with persistent Helicobacter pylori infection after two treatments were studied. Patients were considered positive if two of three endoscopic tests were positive. Susceptibility testing was also performed. Patients received a standard dose of proton-pump inhibitors twice daily, levofloxacin 250 mg twice daily and amoxicillin 1 g twice daily, for 10 days. Endoscopic follow-up was carried out 4-6 weeks after the end of eradication therapy.
RESULTS: About 76% (95% CI: 68.8-82.3), and 85% (95% CI: 77.5-89.7) ofpatients were eradicated according to intention-to-treat and per-protocol analysis, respectively. Eradication rates of the strains showed as 92% (95% CI: 83.2-96.7) of those resistant to both metronidazole and clarithromycin but susceptible to levofloxacin.
CONCLUSIONS: In patients who failed previous regimens, the 10-day levofloxacin-based triple therapy is safe and effective, allowing eradication in almost 80% of the patients.
Department of Internal Medicine and Gastroenterology, University of Bologna, Bologna, Italy.
Systematic review and meta-analysis: proton pump inhibitor vs. ranitidine bismuth citrate plus two antibiotics in Helicobacter pylori eradication.
Gisbert JP, Gonzalez L, Calvet X
OBJECTIVE: To systematically review the Helicobacter pylori eradication efficacy with ranitidine bismuth citrate (RBC) and two antibiotics, and to conduct a meta-analysis of randomized clinical trials comparing the efficacy of proton pump inhibitor (PPI) vs. RBC with two antibiotics for 1 week.
SELECTION OF STUDIES: Studies evaluating RBC plus two antibiotics were considered. For the meta-analysis, randomized controlled trials comparing PPI vs. RBC plus two antibiotics for 1 week were included.
SEARCH STRATEGY: Electronic and manual bibliographical searches. Assessment of study quality and data extraction: Independently done by two reviewers.
DATA SYNTHESIS: 'Intention-to-treat' eradication rate. Meta-analysis was performed, combining the odds ratios (OR) of the individual studies. Subanalysis: Depending on the type ofantibiotics and the quality of the studies.
RESULTS: Mean H. pylori eradication with 7-day RBC-clarithromycin-amoxicillin, RBC-clarithromycin-nitroimidazole, and RBC-amoxicillin-nitroimidazole was 83%, 86%, and 71%, respectively. The meta-analysis showed comparable efficacy with RBC and PPI when they were combined with clarithromycin and amoxicillin (OR = 1.11; 95% CI = 0.88-1.40), or with amoxicillin and metronidazole (OR = 0.92; 95%CI = 0.60-1.41). However, when comparing PPI vs. RBC plus clarithromycin and a nitroimidazole, higher cure rates with RBC than with PPI were demonstrated (OR = 1.65; 95% CI = 1.15-2.37).
CONCLUSION: The efficacy of RBC and PPI-based triple regimens were comparable when using the clarithromycin-amoxicillin or the amoxicillin-metronidazole combination. However, RBC seems to have a higher efficacy than PPI when clarithromycin and a nitroimidazole are the antibiotics prescribed. Therefore, if one prefers to use the clarithromycin-nitroimidazole regimen, RBC should be used instead of a PPI.
Department of Gastroenterology, University Hospital of La Princesa, Madrid, Spain. email@example.com
Meta-analysis: the efficacy, adverse events, and adherence related to first-line anti-Helicobacter pylori quadruple therapies.
Fischbach LA, van Zanten S, Dickason J
Aliment Pharmacol Ther. 2004;20(10):1071.
BACKGROUND: Owing to rising drug-resistant Helicobacter pylori infections, currently recommended proton-pump inhibitor-based triple therapies are losing their efficacy, and regimens efficacious in the presence of drug resistance are needed.
AIMS: To summarize the efficacy, safety and adherence of first-line quadruple H. pylori therapies in adults.
METHODS: Meta-regression models identified factors explaining variation in the efficacy of first-line quadruple therapies from 145 treatment arms. Estimates of average efficacy were calculated within homogeneous groups.
RESULTS: Quadruple therapy containing a gastric acid inhibitor, bismuth, metronidazole and tetracycline was enhanced when omeprazole was included, treatment duration lasted 10-14 days, and when therapy took place in the Netherlands, Hong Kong and Australia. Treatment efficacy decreased as the prevalence of metronidazole resistance increased. Even in areas with a high prevalence of metronidazole resistance, this quadruple regimen eradicated more than 85% of H. pylori infections when it contained omeprazole and was given for 10-14 days. Furthermore, in the presence of clarithromycin resistance, this quadruple regimen eradicated 90-100% of H. pylori infections, while the currently recommended triple therapy containing clarithromycin, amoxicillin and a proton-pump inhibitor eradicated only 25-61% (P<0.001). Adherence and adverse events for quadruple therapy were similar to currently recommended triple therapies.
CONCLUSIONS: Guidelines should include quadruple therapy with a proton-pump inhibitor, a bismuth compound, metronidazole and tetracycline among recommended first-line anti-H. pylori therapies.
School of Public Health, University of Texas, Dallas Regional Campus, Dallas, TX, USA. firstname.lastname@example.org
Meta-analysis: proton pump inhibitor or H2-receptor antagonist for Helicobacter pylori eradication.
Graham DY, Hammoud F, El-Zimaity HM, Kim JG, Osato MS, El-Serag HB
Aliment Pharmacol Ther. 2003;17(10):1229.
AIM: To compare H2-receptor antagonists and proton pump inhibitors as adjuvants to triple therapy for Helicobacter pylori eradication.
METHODS: H. pylori-infected patients with peptic ulcer were randomized to receive either 300 mg nizatidine or 30 mg lansoprazole plus 1 g amoxicillin and 500 mg clarithromycin taken b.d. for 7 days. H. pylori eradication was assessed 4 weeks after therapy. Using meta-analytical techniques, we combined the results of this study with other randomized controlled comparisons of H2-receptor antagonists and proton pump inhibitors as adjuvants to triple therapy.
RESULTS: One hundred and one patients were randomized. H. pylori eradication was 94% (47/50) [95% confidence interval (CI), 83-99%](intention-to-treat) in the H2-receptor antagonist group vs. 86% (44/51) (95% CI, 74-94%) in the proton pump inhibitor group (P = 0.3). There has been a total of 12 similar studies (1415 patients). The overall efficacy was similar in intention-to-treat analysis: 78% (549/701) with H2-receptor antagonists vs. 81% (575/714) with proton pump inhibitors(odds ratio, 0.86; 95% CI, 0.66-1.12). A non-significant trend favouring H2-receptor antagonist (79% vs. 69%; odds ratio, 1.14; 95% CI, 0.76-1.71; P = 0.5) was seen in the comparison of clarithromycin-containing regimens. In contrast, in non-clarithromycin-containing trials, there was a slight, but significant, advantage with proton pump inhibitors (85% vs. 78%; odds ratio, 0.64; 95% CI, 0.45-0.92; P = 0.02).
CONCLUSION: Overall, proton pump inhibitor and H2-receptor antagonist antisecretory agents appear to be similarly effective as adjuvants for H. pylori triple therapy. It is unlikely that the direct anti-H. pylori effect of proton pump inhibitors is responsible for their ability to enhance anti-H. pylori therapy.
Department of Medicine, Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX 77030, USA. email@example.com