Meta-analysis: four-drug, three-antibiotic, non-bismuth-containing "concomitant therapy" versus triple therapy for Helicobacter pylori eradication.
BACKGROUND
Low success rates with triple therapy for Helicobacter pylori infections have prompted search for alternatives. In one, a proton-pump inhibitor (PPI) and amoxicillin was followed by the PPI plus clarithromycin and a nitroimidazole (sequential therapy); in another, these four drugs were given concomitantly (concomitant therapy).


OBJECTIVE
To compare concomitant therapy with standard triple therapy for H. pylori infection.


METHODS
By searching PubMed, EMBASE, the Cochrane Central Register of Controlled Trials and abstracts of major gastrointestinal meeting, two independent reviewers systemically identified randomized controlled trials (RCT) comparing concomitant quadruple to standard triple therapies as well as studies reporting eradication rates of concomitant quadruple therapy in treatment of H. pylori. Pooled eradication rates and odds ratios (OR) with 95% confidence intervals (CI) were calculated, and univariable metaregression analysis for all extracted variables was conducted.


RESULTS
We identified nine studies (10 treatment arms) including five qualifying RCTs (576 subjects) comparing concomitant (293 subjects, duration 3 to 5 days) and triple therapy (283 subjects, duration 5 to 10 days) and four other studies evaluating concomitant therapy (478 subjects, duration 3 to 7 days). Pooled estimates of the five RCTs showed superiority of concomitant therapy over triple therapy; with intention-to-treat) pooled OR of 2.86 (95% CI: 1.73-4.73) and per-protocol (PP) pooled OR of 3.52 (95% CI: 1.95-6.38). Considering all 10 treatment arms, the ITT eradication rate was 89.7% (95% CI: 86.8-92.1%) and PP was 92.9% (95% CI: 90.2-94.8%).


CONCLUSIONS
Concomitant therapy appears to be an effective alternative to triple therapy and is less complex than sequential therapy.
Essa
Abdallah Said
AS
Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
Kramer
Jennifer Rosenthal
JR
Graham
David Y
DY
Treiber
Gerhard
G
D000328:Adult; D000368:Aged; D000658:Amoxicillin / Q000627:therapeutic use; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D017291:Clarithromycin / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D005260:Female; D016481:Helicobacter Infections / Q000188:drug therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009593:Nitroimidazoles; D054328:Proton Pump Inhibitors / Q000627:therapeutic use; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome
D000900:Anti-Bacterial Agents; D009593:Nitroimidazoles; D054328:Proton Pump Inhibitors; D000658:Amoxicillin; D017291:Clarithromycin