Clarithromycin and tetracycline shortages will bring up more questions about appropriate drug regimens for H. pylori (see Table 1). Triple therapy with a proton pump inhibitor (PPI), clarithromycin, and amoxicillin or metronidazole is often used first-line, but usually should NOT be. Efficacy rates are falling due to increasing clarithromycin resistance. For further information, see note, "Peptic ulcer, assessment and management".
Recommend starting with quadruple or concomitant therapy instead. Quadruple therapy with bismuth, metronidazole, and tetracycline plus a PPI is making a comeback due to better efficacy. If tetracycline is not available, physicians will ask about using doxycycline instead. Explain that some experts are trying doxycycline but there's no evidence that it works as well. Suggest other alternatives. Concomitant therapy means triple therapy with a PPI, clarithromycin, and amoxicillin PLUS metronidazole to help boost efficacy.
-
Physicians may prescribe combination packs like (Helicure, Peptic Care). Combination packs like (Helicure, Peptic Care) contain omeprazole 20 mg, clarithromycin 250 mg (while evidanced-guideline dose 500 mg) and tinidazole 500 mg. These combinations are usually prescribed by dose: one tablet twice daily. If patients get Helicure, Peptic Care medications recommend an extra clarithromycin 250 mg tab with the time doses of Helicure or Peptic Care to overcome resistance. OR replace them by Trio-Clar (contain omeprazole 20 mg, clarithromycin 500 mg and tinidazole 500 mg).
Combination packs like Helidac or Pylera (NOT available in Egypt) contain tetracycline. If patients get Helidac, recommend an extra metronidazole 250 mg tab with the three mealtime doses of Helidac to overcome resistance.
Explain this concomitant therapy CAN be used instead of quadruple therapy. It's given BID instead of QID. And it doesn't contain bismuth, so it avoids the black stools or tongue, constipation, etc. Don't recommend another macrolide instead of clarithromycin, these don't work for H. pylori. Tell physicians that extended-release clarithromycin (Klacid XL) will probably work, but this isn't proven. If necessary, ask if antibiotics can be delayed until optimal ones are available. Suggest giving a PPI right away to heal the ulcer and the antibiotic regimen later to help prevent recurrence.
| Table (1). Summary of typical regimens for H. pylori | |
|---|---|
| Treatment regimen | Typical drug combination and dosage |
| Classic triple therapy | PPI, clarithromycin (500 mg) and one of amoxicillin (1 g), metronidazole (500 mg) and tinidazole (500 mg) twice daily for 7 or 14 days |
| Fluoroquinolone‐based triple therapy | PPI, fluoroquinolone and amoxicillin (1 g) twice daily 7 or 14 days |
| Rifabutin triple therapy | PPI, rifabutin (150 mg) and amoxicillin (1 g) twice daily for 14 days |
| Sequential therapy | PPI and amoxicillin (1 g) twice daily for 5 or 7 days, followed by PPI, clarithromycin (500 mg) and one of metronidazole (500 mg) and tinidazole (500 mg) twice daily for 5 or 7 days |
| Concomitant therapy | PPI, clarithromycin (500 mg), amoxicillin (1 g) and one of metronidazole (500 mg) and tinidazole (500 mg) twice daily for 10 or 14 days |
| Bismuth quadruple therapy | PPI, bismuth‐containing compound, metronidazole (400 mg) twice daily and tetracycline (500 mg) four times daily for 14 days |
REFERENCES
-
Mazzoleni, L.E. (2011). Helicobacter pylori Eradication in Functional Dyspepsia. Archives of Internal Medicine, [online] 171(21), p.1929. Available at: https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1106095
Cheng, N.C.L., Xu, K., Huang, Y. and Lim, C.E.D. (2014). Optimum antibiotic doses for Helicobacter pylori eradication. Cochrane Database of Systematic Reviews. Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011187/full