Is quadruple therapy the new triple therapy for H pylori?

Clinical question

Does quadruple therapy (QT) result in superior eradication rates of Helicobacter pylori compared with traditional triple therapy (TT)?

Evidence

A recent industry-funded trial¹ of 440 European patients reported significant benefit with QT for 10 days compared with TT for 7 days (93% vs 68% eradication, number needed to treat 5, P < .001).

• The QT was omeprazole twice daily with bismuth subcitrate, metronidazole, and tetracycline 4 times daily.

• The TT was omeprazole, amoxicillin, and clarithromycin twice daily.

• Concerns: differing treatment durations, differing antibiotics, bismuth subcitrate not commercially available in Canada, and questionable generalizability.

A recent systematic review² found no difference in eradication rates, compliance, or adverse events between QT and TT.

• For example, eradication rates were 78% for QT and 77% for TT (not statistically different).

Context

• Eradication rates for H pylori might be suboptimal (< 80%) worldwide,^3–5 owing to increasing antibiotic resistance.

  • -Resistance varies by geographic region, and local resistance patterns are often not known.⁶

• Clarithromycin resistance should guide initial H pylori treatment choices.

  • -Avoid clarithromycin if resistance rates are ≥ 20%.⁷

• Antibiotic resistance in H pylori treatment does not appear to be a problem in Canada,⁶ although updated rates are lacking.

• Canadian recommendations include TT or QT as first-line therapy for H pylori eradication, but prefer TT owing to demonstrated equivalency and ease of dosing.⁸

• Cost-effectiveness data comparing QT and TT are lacking.

• Other options being studied include sequential therapy (1 course followed by another) and hybrid therapies (sequential and QT).⁹ These require more research in North America before application to practice.¹⁰

Bottom line

Optimal treatment for H pylori remains controversial, with differences in number and type of drugs, dosing, and length of treatment suggested. Until local resistance patterns are identified and deemed a concern, there is no overwhelming evidence to change current prescribing patterns in primary care.

Implementation

Avoiding antibiotics that the patient has previously used (for H pylori eradication or other illnesses) will increase eradication success.¹¹ Eradication should be confirmed in patients with peptic ulcer disease, mucosa-associated lymphoid tissue lymphoma, or resected gastric cancer, and in those with persistent dyspepsia for whom the test-and-treat strategy was used.¹¹ Length of treatment remains controversial. Lengthening TT beyond 7 days might lead to marginal additional benefit.¹² Although some guidelines recommend TT for up to 14 days,^7,11 others (including Canadian guidelines) recommend 7 to 10 days of treatment.⁸