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First-line therapies for H. pylori infection

First-line therapies for H. pylori infection
Regimen Drugs (doses) Dosing frequency Duration (days) FDA approval
Bismuth quadruple PPI (standard dose) Twice daily 10 to 14 No§

Bismuth subcitrate (120 to 300 mg [not available in US] or 420 mg [available in North America and elsewhere as part of Pylera combination pill])[1]

or

Bismuth subsalicylate (300 or 524 mg)[1]
Four times daily
Tetracycline (500 mg) Four times daily
Metronidazole (250 to 500 mg) Four times daily (250 mg)
Three to four times daily (500 mg)
Clarithromycin triple* PPI (standard or double the standard dose) Twice daily 14 YesΔ
Clarithromycin (500 mg) Twice daily

Amoxicillin (1 gram)

or

Metronidazole (500 mg)

Twice daily (amoxicillin)

Three times daily (metronidazole)
Clarithromycin-based concomitant* PPI (standard dose) Twice daily 10 to 14 No
Clarithromycin (500 mg) Twice daily
Amoxicillin (1 gram) Twice daily
Metronidazole or tinidazole (500 mg) Twice daily
Clarithromycin-based sequential¥* PPI (standard dose) plus amoxicillin (1 gram) for 5 days followed by: Twice daily 10 (total) No
PPI, clarithromycin (500 mg) plus either metronidazole or tinidazole (500 mg) for an additional 5 days Twice daily
Clarithromycin-based hybrid‡* PPI (standard dose) plus amoxicillin (1 gram) for 7 days followed by: Twice daily 14 (total) No
PPI, amoxicillin, clarithromycin (500 mg), plus either metronidazole or tinidazole (500 mg) for an additional 7 days Twice daily
FDA: United States Food and Drug Administration; PPI: proton pump inhibitor.
* In patients with risk factors for macrolide resistance, clarithromycin-based therapy should be avoided.
¶ Standard doses of orally administered proton pump inhibitors include: Lansoprazole 30 mg daily, omeprazole 20 mg daily, pantoprazole 40 mg daily, rabeprazole 20 mg daily, or esomeprazole 20 mg daily.
Δ Several PPI, clarithromycin, and amoxicillin combinations have achieved FDA approval. PPI, clarithromycin, and metronidazole is not an FDA-approved treatment regimen.
14 days is recommended. Refer to UpToDate topic on treatment for H. pylori infection.
§ PPI, bismuth, tetracycline, and metronidazole prescribed separately is not an FDA-approved treatment regimen. However, Pylera (a fixed-dose capsule containing bismuth subcitrate, tetracycline, and metronidazole) combined with a PPI for 10 days, and Helidac (a copackaged product containing bismuth subsalicylate, tetracycline, and metronidazole) combined with a PPI for 14 days, are FDA-approved treatment regimens. For additional information, refer to the Lexicomp drug monographs included within UpToDate.
¥ Some North American guidelines do not support the use of sequential therapy.
‡ Hybrid therapy has not been universally endorsed as an option for first-line therapy.
Reference:
  1. Fallone CA, Chiba N, Van Zanteri et al. The Toronto Consensus for Treatment of Helicobacter pylori infection in Adults. Gastro 2016; 15:51.
Adapted by permission from Macmillan Publishers Ltd: American Journal of Gastroenterology. Chey WD, Leontiadis GI, Howden CW, Moss SF. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol 2017; 112:212. Copyright © 2017. www.nature.com/ajg.
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