title: Sequential therapy versus standard triple-drug therapy for Helicobacter pylori eradication: a systematic review of recent evidence.
abstract: BACKGROUND
  Several alternative treatment regimens for Helicobacter pylori eradication have been proposed since the efficacy of standard triple therapy has declined over time, and sequential therapy is one of them. The purpose of this systematic review is to analyze and compare the efficacy, adverse effects and cost of sequential therapy with that of standard triple therapy for H. pylori infection.
  
  
  METHODS
  MEDLINE, EMBASE, Google Scholar and Cochrane databases were used to retrieve all relevant articles published in the English language over the last 5 years (January 2008-October 2012). Eligibility criteria were randomized controlled trials (RCTs) comparing sequential and standard triple therapies in patients with documented H. pylori infection. Eligibility and quality of the trials were assessed independently by two reviewers, and the data regarding eradication rate, adverse effects and the cost of therapy were extracted.
  
  
  RESULTS
  Of the 17 RCTs included in the analysis (Asia 13, Europe 3, Latin America, 1), 12 reported better eradication rates with the sequential therapy, four did not find a significant difference between the two treatment regimens, and one reported a better eradication rate with standard triple therapy. All except one RCT reported no significant difference in the incidence of adverse effects between standard triple therapy and sequential therapy. Sequential therapy was cheaper than standard triple therapy in all three RCTs where a cost analysis was performed. The limitations of the RCTs included in the systematic review were that the sequential therapy regimen and the duration of standard triple therapy were not uniform. Antibiotic susceptibility tests were performed in only three RCTs.
  
  
  CONCLUSIONS
  While the majority of the RCTs have shown superior eradication rates with sequential therapy, the largest RCT from Latin America did not find a significant difference between the two treatment regimens. Sequential therapy has good efficacy; however, further trials other than those from Asia and Italy are required to assess its superiority over existing regimens before recommending sequential therapy as the first line of treatment for H. pylori infection.
authors.affiliation: Department of General and Gastrointestinal Surgery, Jawaharlal Institute of Post-Graduate Medical Education and Research (JIPMER), Pondicherry 605006, India. drvikramkate@gmail.com
authors.forename: Vikram
authors.initials: V
authors.lastname: Kate
authors.forename: Raja
authors.initials: R
authors.lastname: Kalayarasan
authors.forename: Nilakantan
authors.initials: N
authors.lastname: Ananthakrishnan
mesh_terms: D000658:Amoxicillin / Q000191:economics / Q000627:therapeutic use*; D000900:Anti-Bacterial Agents / Q000191:economics / Q000627:therapeutic use*; D017291:Clarithromycin / Q000191:economics / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis; D004359:Drug Therapy, Combination; D016481:Helicobacter Infections / Q000188:drug therapy* / Q000191:economics; D016480:Helicobacter pylori / Q000187:drug effects*; D006801:Humans; D017410:Practice Guidelines as Topic; D054328:Proton Pump Inhibitors / Q000191:economics / Q000627:therapeutic use*; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents; D054328:Proton Pump Inhibitors; D000658:Amoxicillin; D017291:Clarithromycin