Commentary: Helicobacter pylori eradication in Western Australia – author's reply

Abstract

The letter by Tehami and Nwokolo1 makes valid points, which we are pleased to address. First, our study2 was not meant to compare sequential vs. concurrent therapies. However, the sequential proton pump inhibitor, amoxycillin, rifabutin, chlarithromycin (PARC) therapy was designed years ago when it was reported to have higher efficacy than concurrent therapies. It has the advantage of a benign introductory phase, which always suppresses Helicobacter pylori and which can be expected to commence gastric mucosal healing. The two extra drugs (expensive and with side effects more likely) can then be given for only 5 days. Our preferred therapy for penicillin-allergic patients [proton pump inhibitor, bismuth, rifabutin, chlarithromycin (PBRC)] was designed later on when concurrent therapy showed similar efficacy. As bismuth is a less potent agent than amoxicillin, but with very low toxicity in short courses, we chose to double the dose of that agent to two tablets q.d.s. As we started the study with the sequential PARC therapy, and that worked very well, there was no reason for us to modify the treatment plan before adequate numbers of patients had been entered. Nevertheless, on the basis of several rifabutin-based quadruple therapies reported,3-5 we suspect that a concurrent PARC treatment would be as effective and perhaps the rifabutin dose could be reduced even further. We agree that the high performance of these regimens is an important asset, especially when H. pylori resistance is unknown. We look forward to seeing further studies of these regimens from centres with larger patient resources than ours. The authors’ declarations of personal and financial interests are unchanged from those in the original article.2