H. pylori Eradication Options for Peptic Ulcer Disease

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H. PYLORI INFECTION TREATMENT GUIDELINE
H. PYLORI INFECTION TREATMENT GUIDELINE
                                             
  Is patient allergic to penicillin?  
    No            Yes    
             
 

• Bismuth quadruple

• Levofloxacin triple

• Levofloxacin sequential

 
Yes1
Does patient have
previous macrolide
exposure?
  Does patient have
previous macrolide
exposure?
 
Yes1
Bismuth quadruple  
       
    No            No    
             
 

Recommended

• Bismuth quadruple

• Concomitant

• Clarithromycin triple with amoxicillin

 

Other options

• Sequential

• Hybrid

• Levofloxacin triple

• Levofloxacin sequential

 

• Clarithromycin triple with metronidazole

• Bismuth quadruple

   
 
 
 
 
FIRST-LINE THERAPIES
Regimen Drugs/Dosing Duration (days)
RECOMMENDED

Clarithromycin triple2

PPI (standard or double dose twice daily) + clarithromycin (500mg twice daily) + amoxicillin (1g twice daily) OR metronidazole (500mg three times daily)

14

Bismuth quadruple3

PPI (standard dose twice daily) + bismuth subcitrate (120–300mg 4 times daily) or subsalicylate (300mg 4 times daily) + tetracycline (500mg 4 times daily) + metronidazole (250mg 4 times daily or 500mg 3–4 times daily)

10 –14

Concomitant4

PPI (standard dose twice daily) + clarithromycin (500mg twice daily) + amoxicillin (1g twice daily) + nitroimidazole5 (500mg twice daily)

10 –14

SUGGESTED

Sequential4

PPI (standard dose twice daily) + amoxicillin (1g twice daily) THEN

5 –7

 

PPI + clarithromycin (500mg twice daily) + nitroimidazole5 (500mg twice daily)

5 –7

Hybrid4

PPI (standard dose twice daily) + amoxicillin (1g twice daily) THEN

7

 

PPI + amoxicillin + clarithromycin (500mg twice daily) + nitroimidazole5
(500mg twice daily)

7

Levofloxacin triple4

PPI (standard dose twice daily) + levofloxacin (500mg daily) + amoxicillin
(1g twice daily)

10 –14

Levofloxacin sequential4

PPI (standard or double dose twice daily) + amoxicillin (1g twice daily) THEN

5 –7

 

PPI + levofloxacin (500mg daily) + nitroimidazole5 (500mg twice daily)

5 –7

LOAD4

Levofloxacin (250mg daily) + omeprazole (double dose daily) + nitazoxanide (500mg twice daily) + doxycycline (100mg daily)

7 –10

NOTES

Key: PPI = proton pump inhibitor; LOAD = levofloxacin + omeprazole + Alinia + doxycycline

1 Includes patients in regions where clarithromycin resistance is known to be >15%.

2 Several PPIs (eg, Prilosec, Nexium, Prevacid, Aciphex) in combination with clarithromycin and amoxicillin have achieved FDA approval. FDA-approved combination products include Omeclamox-Pak (omeprazole/amoxicillin/clarithromycin) and Prevpac (lansoprazole/amoxicillin/clarithromycin). PPI + clarithromycin + metronidazole is not an FDA-approved regimen.

3 Not an FDA-approved regimen if prescribed separately. Pylera (bismuth subcitrate/tetracycline/metronidazole) combined with omeprazole for 10 days is FDA-approved.

4 Not an FDA-approved regimen.

5 Metronidazole or tinidazole.

For FDA-approved regimens, see drug monographs at www.eMPR.com or contact company for full drug labeling.

REFERENCES

Chey WD, Leontiadis GI, Howde CW, et al. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection.
Am J Gastroenterol 2017; 112:212-238; doi:10.1038/ajg.2016.563; published online 10 January 2017.

(Rev. 3/2018)

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