A systematic comparison of triple therapies for treatment of Helicobacter pylori infection with proton pump inhibitor/ ranitidine bismuth citrate plus clarithromycin and either amoxicillin or a nitroimidazole.
BACKGROUND
Triple therapies with proton pump inhibitor/ranitidine bismuth citrate (RBC), clarithromycin (C) and either amoxicillin (A) or a nitroimidazole (I) are widely accepted as treatment for Helicobacter pylori infection. However, it is not clear which of these antibiotic combinations should be preferred.


OBJECTIVE
To evaluate whether there is a difference in efficacy between triple therapies with proton pump inhibitor/RBC, clarithromycin and either amoxicillin or a nitroimidazole.


METHODS
The literature was examined for randomized trials comparing proton pump inhibitor/RBC-C-A and proton pump inhibitor/RBC-C-I. Studies were grouped according to the type of acid inhibitor used (proton pump inhibitor or RBC) and differences between pooled cure rates were calculated.


RESULTS
Forty-seven studies were identified: seven using RBC, 39 using proton pump inhibitor, one using both. RBC-C-I was somewhat superior to RBC-C-A, although this difference only reached statistical significance in intention-to-treat analysis. Overall, proton pump inhibitor-C-I and proton pump inhibitor-C-A were equally effective, but in nitroimidazole-susceptible strains, proton pump inhibitor-C-I performed better, in nitroimidazole-resistant strains, proton pump inhibitor-C-A performed better. No serious side-effects were reported and pooled drop-out rates were equal.


CONCLUSIONS
In general, proton pump inhibitor-C-I and proton pump inhibitor-C-A are equally effective and therefore other factors such as local prevalence of resistant strains, cost of therapy and options for second-line treatment should determine which regimen should be preferred. When using RBC, the RBC-C-I combination is somewhat superior to RBC-C-A.
Janssen
M J
MJ
Department of Gastroenterology and Hepatology, University Medical Centre St. Radboud, Nijmegen, The Netherlands. marceljanssen6@hotmail.com
Van Oijen
A H
AH
Verbeek
A L
AL
Jansen
J B
JB
De Boer
W A
WA
D000658:Amoxicillin / Q000008:administration & dosage / Q000627:therapeutic use*; D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D000897:Anti-Ulcer Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D001729:Bismuth / Q000008:administration & dosage / Q000627:therapeutic use*; D017291:Clarithromycin / Q000008:administration & dosage / Q000627:therapeutic use*; D016527:Drug Costs; D004351:Drug Resistance; D004359:Drug Therapy, Combination; D016481:Helicobacter Infections / Q000188:drug therapy* / Q000473:pathology; D016480:Helicobacter pylori / Q000187:drug effects / Q000472:pathogenicity; D006801:Humans; D009593:Nitroimidazoles / Q000008:administration & dosage / Q000627:therapeutic use*; D010347:Patient Care Planning; D010406:Penicillins / Q000008:administration & dosage / Q000627:therapeutic use*; D054328:Proton Pump Inhibitors; D016032:Randomized Controlled Trials as Topic; D011899:Ranitidine / Q000008:administration & dosage / Q000031:analogs & derivatives* / Q000627:therapeutic use*; D016896:Treatment Outcome
D000900:Anti-Bacterial Agents; D000897:Anti-Ulcer Agents; D009593:Nitroimidazoles; D010406:Penicillins; D054328:Proton Pump Inhibitors; C073340:ranitidine bismuth citrate; D000658:Amoxicillin; D011899:Ranitidine; D017291:Clarithromycin; D001729:Bismuth