Pharmacotherapy: A Pathophysiologic Approach, 9e > Chapter 20.

Peptic Ulcer Disease

20-7 Guidelines for the Eradication of Helicobacter pylori Infection Indications for treatment of H. pylori
infection

Established indications for the treatment of H. pylori include gastric or duodenal ulcer, mucosa-associated
lymphoid tissue (MALT) lymphoma, after endoscopic resection of gastric cancer, and uninvestigated
dyspepsia
Controversial indications for the treatment of H. pylori infection include nonulcer dyspepsia,
gastroesophageal reflux disease, individuals taking nonsteroidal antiinflammatory drugs (NSAIDs),
individuals at high risk for gastric cancer, and unexplained iron deficiency anemia

Initial treatment of H. pylori infection

Use only those eradication regimens that are of proven effectiveness in the United States
In the United States, first-line treatment should include a proton pump inhibitor ( PPI), clarithromycin, and
either amoxicillin or metronidazole ( PPI-based triple therapy) for 10–14 days
 The PPI-based triple-therapy amoxicillin-containing regimen is preferred initially because bacterial
resistance to amoxicillin is almost absent, it has fewer adverse effects, and it leaves metronidazole as a
backup agent for second-line therapy
In penicillin-allergic patients, metronidazole should be substituted for amoxicillin in the PPI-based triple-
therapy regimen and yields similar results when combined with clarithromycin
An alternate initial strategy includes a PPI or H2RA, bismuth salt, tetracycline, and metronidazole ( bismuth-
based quadruple therapy) for 10–14 days
Sequential therapy consisting of a PPI and amoxicillin for 5 days followed by a PPI, clarithromycin, and
metronidazole for 5 days is an alternative to PPI-based triple therapy or PPI-based quadruple therapy, but
requires further validation before it can be recommended as first-line therapy in the United States

Eradication of H. pylori after initial treatment failure

Avoid antibiotics that have been used in previous eradication regimens

Bismuth-based quadruple therapy with a bismuth salt, tetracycline, metronidazole, and a PPI or H2RA for
10–14 days is an acceptable treatment regimen for persistent H. pylori infections
PPI-based triple therapy with levofloxacin and amoxicillin for 10 days may be more effective and better
tolerated than PPI-based quadruple therapy with a bismuth salt, tetracycline, and metronidazole, but it
requires further validation in the United States

Data from references 5, 25–29.

Pharmacotherapy: A Pathophysiologic Approach, 9e > Chapter 20. Peptic Ulcer Disease

Table 20-8 Drug Regimens

Used to Eradicate Drug #2 Drug #3 Drug #4
Helicobacter pylori Drug #1

Proton Pump Inhibitor–Based Triple Therapya

PPI once or twice dailyb Clarithromycin 500 Amoxicillin 1 g twice daily

mg twice daily or metronidazole 500 mg
twice daily

Bismuth-Based Quadruple Therapya

PPI or H2RA once or twice Bismuth subsalicylated Metronidazole 250–500 Tetracycline 500 mg
dailyb,c 525 mg four times mg four times daily four times daily
daily
Table 20-8 Drug Regimens
Used to Eradicate Drug #2 Drug #3 Drug #4
Helicobacter pylori Drug #1

Sequential Therapye

PPI once or twice daily on Amoxicillin 1 g twice Metronidazole 250–500 Clarithromycin 250–500
days 1–10b daily on days 1–5 mg twice daily on days 6– mg twice daily on days
10 6–10

Second-Line (Salvage) Therapy for Persistent Infections

PPI or H2RA once or twice Bismuth subsalicylated Metronidazole 250–500 Tetracycline 500 mg
dailyb,c 525 mg four times mg four times daily four times daily
daily

PPI once or twice dailyb,f Amoxicillin 1 g twice Levofloxacin 250 mg

daily twice daily

H2RA, H2-receptor antagonist; PPI, proton pump inhibitor.

a
Although treatment is minimally effective if used for 7 days, 10–14 days is recommended. The
antisecretory drug may be continued beyond antimicrobial treatment for patients with a history of a
complicated ulcer, for example, bleeding, or in heavy smokers.
b
Standard PPI peptic ulcer healing dosages given once or twice daily.
c
Standard H2RA peptic ulcer healing dosages may be used in place of a PPI.