What are the treatment options for H pylori chronic gastritis?

Updated: Jun 07, 2019
  • Author: Akiva J Marcus, MD, PhD; Chief Editor: BS Anand, MD  more...
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Answer

At first, specific recommendations for H pylori eradication were limited to peptic ulcer disease. However, the 1997 Digestive Health Initiative (DHI) International Update Conference on H pylori broadened the recommendations for H pylori testing and treatment. H pylori testing and eradication were also recommended after resection of early gastric cancer and for low-grade mucosa-associated lymphoid tissue (MALT) lymphoma. Furthermore, it is now widely accepted that if H pylori is identified as the underlying cause of gastritis, it should be eradicated.

H pylori infection is not easily cured, and research has shown that multidrug therapy is required. As with any bacterial infection, therapy must include antimicrobial agents to which the bacterium is sensitive. Antibiotics that have proven effective against H pylori include clarithromycin, amoxicillin, metronidazole, tetracycline, and furazolidone. Cure rates with single antibiotics have been poor (0%-35%). Monotherapy is associated with the rapid development of antibiotic resistance, especially to metronidazole and clarithromycin. Probiotic supplementation has shown promising results when included in the treatment regimen. [100, 101]

Five regimens are approved by the US Food and Drug Administration (FDA) for the treatment of H pylori infection. One is a version of the traditional bismuth-metronidazole-tetracycline (BMT) triple therapy, which is commercially available as Helidac (Prometheus Laboratories, San Diego, CA). The antibiotics and bismuth are provided in a convenient dose pack that is thought to enhance compliance.

Three different combinations using clarithromycin have been approved, including 2 dual therapies consisting of 500 mg of clarithromycin 3 times daily plus either omeprazole or ranitidine bismuth citrate. The cure rates reported in the packaging literature suggest that the 3 combinations are similarly effective.

Clinical experience has shown that the most effective of these regimens is BMT triple therapy, followed by ranitidine bismuth citrate plus clarithromycin and then by omeprazole plus clarithromycin.

Because higher success rates can be achieved when a third drug is added to the dual therapies, most authorities now recommend triple-drug combinations. This recommendation was confirmed by the FDA’s approval of a combination regimen comprising the proton pump inhibitor (PPI) lansoprazole, clarithromycin, and amoxicillin. The cure rate with this combination exceeds 85%. A 2-drug regimen consisting of lansoprazole plus amoxicillin was also approved, but it yields tremendously variable results and thus is a very poor choice.


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