Which Therapy for Helicobacter pylori Infection?

A combination of esomeprazole and 3 antimicrobial agents is less expensive and complex, and equally or more effective, than sequential regimens for eradication of  Helicobacter pylori infectionaccording to the July issue of Gastroenterology.

H pylori infection causes stomach cancer in 20% of infected subjects, so it is important to eliminate. Although many different types of antimicrobial drugs can be used, it is a challenge to cure the infection, because the bacteria acquire resistance. In the US, resistance has undermined clarithromycin-containing therapy, and fluoroquinolone resistance is increasing rapidly worldwide.

H pylori

Combination strategies have been developed to overcome resistance, but these have not compared directly, so clinicians are not sure which strategy is best. Ten days of sequential therapy with an acid-suppressive agent (a proton-pump inhibitor such as esomeprazole), followed by a sequence of 3 antimicrobial agents (amoxicillin, levofloxacin, and tinidazole) has good eradication rates in areas of clarithromycin resistance. However, adherence to these complicated regimens is a major determinant of their efficacy.

Alessandro Federico et al. tested whether it is easier, more effective, and cheaper to give patients these drugs all at once, for 5 days. They gave 90 patients with H pylori infection 5 days of concomitant therapy (40 mg esomeprazole twice daily along with 1 g amoxicillin twice daily, 500 mg levofloxacin twice daily, and 500 mg tinidazole twice daily). They compared outcomes with those of 90 patients given 10 days of sequential therapy (40 mg esomeprazole twice daily and 1 g amoxicillin twice daily for 5 days, followed by 5 days of 40 mg esomeprazole twice daily, 500 mg levofloxacin twice daily, and 500 mg tinidazole twice daily).

The approaches were almost equally effective— the concomitant therapy eradicated the infection in 96.5% of patients, whereas the sequential therapy worked for 95.5% of the patients. However, concomitant therapy cost $9 less than sequential therapy. Federico et al. say that considering the large number of patients who need treatment, this small amount of savings per patient could add up to significant savings for public health systems.

Because the 5-day regimen was easy to follow and also well tolerated, Federico et al. conclude that it is good approach for areas where the efficacy of triple therapy is unacceptably low. In an editorial that accompanies the article, David Y. Graham and Akiko Shiotani say that they prefer concomitant therapy because it is less complex and it retains its efficacy at slightly higher levels of resistance than sequential therapy.

The editorial authors state that the levofloxacin concomitant regimen described by Federico et al. combines success, simplicity, and cost savings, compared with the same drugs used as sequential therapy.

More Information on H pylori Infection:

Read the article online. This article has accompanying CME activities.
Federico A, Nardone G, Gravina AG, et al. Efficacy of 5-day levofloxacin-containing concomitant therapy in eradication of Helicobacter pylori infection. Gastroenterology 2012;143:55–61.e1.

Read the accompanying editorial.
Graham DY, Shiotani A. Which therapy for Helicobacter pylori infection? Gastroenterology 2012;143:10–12.

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