First-Line Therapies

Proton-Pump-Inhibitor–Based Triple Therapies
• Treatment of H Pylori twice daily for seven days with 20 mg of omeprazole, given either with 1 g of amoxicillin and 500 mg of clarithromycin, or with 400 mg of metronidazole and 250 mg of clarithromycin [16].
• Several comparative trials have demonstrated the equivalence of 30 mg of lansoprazole twice daily, 40 mg of pantoprazole twice daily, 20 mg of rabeprazole daily, and 20 mg of esomeprazole twice daily with omeprazole in these triple therapies [16].
• The duration of therapy remains controversial. In Europe, 7-day treatment is recommended,whereas in the United States, 14-day courses have been found to be better than shorter courses and are approved by the FDA. In a recent meta-analysis, 14-day treatment achieved rates of cure 7 to 9 percentage points better than 7-day treatment [16].
• Primary resistance to clarithromycin and metronidazole decreases rates of cure by 50 percent and 37 percent, respectively [16].

Ranitidine Bismuth Citrate–Based Therapies
• Ranitidine bismuth citrate in dual therapy with clarithromycin for two weeks has been approved by the FDA [16].
• Bismuth citrate with clarithromycin and amoxicillin, or with clarithromycin and a nitroimidazole, performs as well as corresponding proton-pump-inhibitor–based therapies [16].
• Ranitidine bismuth citrate–based regimens may be less influenced by antibiotic resistance than their proton-pump-inhibitor–based counterparts. No ranitidine bismuth citrate–based triple therapy has been approved by the FDA [16].

Bismuth-Based Triple Therapies
• A proton-pump inhibitor, clarithromycin, and either amoxicillin or metronidazole for two weeks; ranitidine bismuth citrate, clarithromycin, and amoxicillin, metronidazole, or tetracycline for two weeks; and a proton-pump inhibitor, bismuth, metronidazole, and tetracycline for one to two weeks had been approved earlier [16].
• The regimens recommended by the European Maastricht 2–2000 conference are a proton-pump inhibitor (or ranitidine bismuth citrate), clarithromycin, and amoxicillin or metronidazole for seven days [16].
Second-Line Therapies
• Eradication is more difficult when a first treatment attempt has failed, usually because of either poor patient compliance or the development of antibiotic resistance. Therefore, a 10-to-14-day treatment course is advocated for second-line therapies [16].
• However, the optimal strategy for retreatment after the failure of eradication has not yet been established [16].
• Because the failure of therapy is often associated with secondary antibiotic resistance, retreatment should ideally be guided by data on susceptibility. However, such information is often unavailable, so quadruple therapies, in which a proton-pump inhibitor or an H2-receptor antagonist is added to a bismuth-based triple regimen with high-dose metronidazole, have been suggested as optimal second-line therapy [16].
• Another approach to retreatment without susceptibility testing is to prescribe a second course of proton-pump-inhibitor–based triple therapy, avoiding antimicrobial agents against which prior therapy may have induced resistance and avoiding less effective combinations, such as amoxicillin and tetracycline [16].
• If a clarithromycin-based regimen is used first, a metronidazole-based regimen should be used afterward, or vice versa [16].
• Alternative approaches to second-line proton-pump-inhibitor–based therapies have been reported recently, but mostly in abstract form. Rifabutin, given in association with amoxicillin and pantoprazole for 10 days, achieved an 86 percent rate of cure, even in patients with resistant strains [16].
• Regardless of which therapy course is chosen, patients with significant symptoms at presentation may continue to use a standard dose of a PPI for 3 extra weeks at the end of the combination drug treatment. The optimal rates of eradication are obtained within 14-day dosing but 7-day dosing are almost similar
Patients on nonsteroidal anti-inflammatory drugs (NSAIDs)
• Patients on NSAIDs should have these discontinued if possible.
• If it is not possible to discontinue NSAIDs, duration of PPI therapy of 12 weeks is recommended.
• In person with symptoms and risk factors, refer for endoscopy [14].
• If ongoing symptom relief is needed [14]:
• Continue NSAID with co prescription of PPI or misoprostol OR
• Replace NSAID with cyclo-oxygenase-2 (COX-2) selective inhibitor.

• Eradicate H. pylori if testing is positive [14].