May 03, 2016
By Will Boggs MD
NEW YORK (Reuters Health) - New Toronto consensus guidelines recommend more intense, longer duration treatment of Helicobacter pylori in adults.
"The current recommendations stress the importance of quadruple therapy and recommend either concomitant non-bismuth or bismuth quadruple therapy as the first-line choices," Dr. Carlo A. Fallone, from McGill University Health Center, Quebec, Canada, told Reuters Health by email. "In addition and very importantly, the consensus is to prolong the duration of the treatments to 14 days."
With the increasingly frequent failures of triple therapies for H. pylori, and in light of new therapies, the Canadian Association of Gastroenterology and the Canadian Helicobacter Study Group recognized that the adult treatment guidelines required updating.
Accordingly, Dr. Fallone and colleagues undertook a consensus process to systematically review the literature relating to the management of H. pylori infection and to provide specific, updated recommendations for eradication therapy in adults.
Their principal recommendation is for a treatment duration of 14 days to replace the older 10-day treatment.
For first-line therapy, the consensus recommendations suggest the combination of a proton pump inhibitor (PPI), bismuth, metronidazole, plus tetracycline for most patients. The quadruple combination of a PPI, amoxicillin, metronidazole, and clarithromycin is a recommended alternative.
Only in areas where clarithromycin resistance is low (<15%) or local eradication rates are high (>85%), a triple regimen might be considered, according to the April 18 online report in Gastroenterology.
Levofloxacin triple therapy and sequential non-bismuth quadruple therapy were not recommended for first-line therapy.
For patients who have failed a clarithromycin- or levofloxacin-containing H. pylori eradication therapy, the consensus recommends against the use of clarithromycin- or levofloxacin-containing regimens as subsequent therapy.
The guidelines also recommend against adding probiotics to the regimen either to reduce adverse events or to increase eradication rates, because the quality of the evidence to support these practices is very low.
"There are some that would argue that treatment choice should be based on susceptibility testing," Dr. Fallone explained. "Susceptibility testing, however, is not easily available and often not practical in that it requires endoscopy. The consensus agreed that the choice of treatment should consider susceptibility testing in individuals, or utilize local population prevalence of antibiotic resistance, or even utilize local treatment success rates of specific treatments if available, but it also provides an empiric choice of treatments for the infection based on the literature for the majority of physicians, where this information is not available."
"High-dose dual therapy is an option that needs further study," Dr. Fallone said. "Preliminary results are good, but at this point, insufficient for recommendation."
Dr. Jaw-Town Lin from Fu-Jen Catholic University, New Taipei City, Taiwan and Dr. Jyh-Ming Liou from National Taiwan University, Taipei, Taiwan told Reuters Health by email, "A recent meta-analysis showed that 14-day sequential therapy was superior to 14-day triple therapy. Therefore, more evidence on the 14-day sequential therapy would be needed to recommend or recommend against the use of 14-day sequential therapy in the first-line treatment."
"Head-to-head randomized controlled trials are warranted to compare the efficacies of bismuth versus non-bismuth quadruple therapies, 10-day versus 14-day quadruple regimens (bismuth and non-bismuth), as well as more potent versus standard acid suppression agents (agent/dose/frequency)," they concluded.
The authors reported no external funding. A number of authors reported disclosures.
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