Finding the optimum treatment for Helicobacter pylori

Abstract

F! Moayyedi Medical progress is characterized by a series of small steps and occasional bigger jumps. Helicobacter pylori (H. pylori) eradication therapy is a good example of this phenomenon. Initial research into H. pylori was hampered by the lack of effective therapy against the organism. The discovery that two weeks of bismuth based triple therapy l and dual therapy with a proton pump inhibitor (PPI) and amoxicillin 2 eradicated H. pylori opened new horizons for research. A direct causal link between H. pylori and peptic ulcer disease could now be established in randomised controlled trials 3 and this dramatically altered our approach to treating patients with an ulcer diathesis. This initial enthusiasm was tempered by the realisation that eradication rates were very variable with these classical therapies 4. The next jump in the progress of H. pylori therapy came with the description of PPI based triple regimens 5-7. These were reported to have eradication rates of 90-95% with few adverse events 8. Bazzoli et al. 6 were the most influential of these studies as low doses of antibiotic were used for only one week resulting in safer, simpler and cheaper therapy compared with the two weeks regimens. This became particularly important as H. pylori eradication therapies became more widely used, as from a public health perspective the exposure of bacterial flora to antibiotics should be minimised 9. The shorter the course, the better, and soon the duration of other PPI triple therapies were reduced to one week without apparent loss in efficacy lo. Progress in H. pylori eradication therapy has occurred in smaller steps since these landmark papers and we still have much to learn.