Quadruple therapy for Helicobacter pylori infection

Abstract

We read with interest the article by Jyh-Ming Liou and colleagues (Jan 19, p 205),1Liou JM Chen CC Chen MJ et al.Sequential versus triple therapy for the first-line treatment of Helicobacter pylori: a multicentre, open-label, randomised trial.Lancet. 2013; 381: 205-213Summary Full Text Full Text PDF PubMed Scopus (202) Google Scholar in which the authors demonstrate an advantage of 14-day sequential therapy over 14-day triple therapy (90·7% vs 82·3% on an intention-to-treat basis), in a setting with a low rate of clarithromycin resistance (9%). 14-day triple therapy, on account of suboptimal results, might be an insufficient therapy even upon favourable antimicrobial circumstances. One of the most striking findings of Liou and colleagues' study1Liou JM Chen CC Chen MJ et al.Sequential versus triple therapy for the first-line treatment of Helicobacter pylori: a multicentre, open-label, randomised trial.Lancet. 2013; 381: 205-213Summary Full Text Full Text PDF PubMed Scopus (202) Google Scholar is that the efficacy of sequential therapy is impaired by antimicrobial resistance. Keeping in mind cure rates and clarithromycin resistance, it is predictable that 14-day sequential therapy would not reach acceptable eradication rates in settings with clarithromycin resistance ≥15–20%, as recently shown in Spain and Italy.2Gisbert JP Calvet X O'Connor A et al.Sequential therapy for Helicobacter pylori eradication: a critical review.J Clin Gastroenterol. 2010; 44: 313-325Crossref PubMed Scopus (2) Google Scholar So far, no trials have compared bismuth and non-bismuth quadruple therapies. The bottom line, therefore, is to ascertain whether in challenging settings (eg, with high resistance rates) we should switch to bismuth therapy, as suggested in the Maastricht IV guidelines, or whether it might be worth trying other non-bismuth quadruple regimens—namely, concomitant and hybrid therapy. In two recent trials3Wu DC Hsu PI Wu JY et al.Sequential and concomitant therapy with 4 drugs are equally effective for H pylori infection.Clin Gastroenterol Hepatol. 2010; 8: 36-41Summary Full Text Full Text PDF PubMed Scopus (207) Google Scholar, 4Huang YK Wu MC Wang SS et al.Lansoprazole-based sequential and concomitant therapy for the first-line Helicobacter pylori eradication.J Dig Dis. 2012; 13: 232-238Crossref PubMed Scopus (56) Google Scholar comparing sequential therapy and concomitant (same drugs given concurrently) therapy, clarithromycin resistance influenced the effectiveness of sequential therapy, but not that of the concomitant regimen. On the other hand, hybrid therapy (combining sequential and concomitant therapy), with promising pilot results, has been shown to be superior to sequential therapy.5Sardarian H Fakheri H Hosseini V et al.Comparison of hybrid and sequential therapies for Helicobacter pylori eradication in Iran: a prospective randomized trial.Helicobacter. 2013; 18: 129-134Crossref PubMed Scopus (77) Google Scholar Further studies comparing different non-bismuth quadruple regimens, and these to bismuth quadruple treatment, are warranted to clarify H pylori first-line therapeutic algorithm. We declare that we have no conflicts of interest. Sequential versus triple therapy for the first-line treatment of Helicobacter pylori: a multicentre, open-label, randomised trialOur findings lend support to the use of sequential treatment as the standard first-line treatment for H pylori infection. Full-Text PDF Quadruple therapy for Helicobacter pylori infection – Authors' replyWe agree that it is now important to assess the efficacy of quadruple therapies since the eradication rate of triple therapy is declining rapidly. Full-Text PDF