How Can the Current Strategies for Helicobacter pylori Eradication Therapy be Improved?

BACKGROUND: The use of Helicobacter pylori eradication therapy is advocated in an increasing variety of situations. It is therefore important to optimise current strategies to eradicate H pylori infection. OBJECTIVES: To define the optimum dosage, drugs and duration of proton pump inhibitor (PPI) triple therapy. METHODS: A review of the literature was performed to identify randomized controlled trials and systematic reviews addressing these issues. RESULTS: In PPI, amoxicillin and clarithromycin (PAC) based regimens, twice daily PPI gave optimal eradication rates (relative risk reduction [RRR] compared with once daily = 7%; 95% CI 2% to 12%), but in PPI, clarithromycin and metronidazole (PCM) based regimens there was no difference (RRR = 2%; 95% CI -7% to 10%). Omeprazole and lansoprazole-containing triple therapies achieved similar eradication rates, but rabeprazole appeared superior to omeprazole (RRR = 8%; 95% CI 2% to 14%). The optimum clarithromycin dose in a PAC regimen was 500 mg twice daily (RRR = 11%; 95% CI = 3% to 18%), but 250mg twice daily in a PCM regimen (RRR = 2%; 95% CI -4% to 7%). Eradication rates were lower with a seven day regimen compared with fourteen (RRR = 12%; 95% CI 7% to 17%). Overall there was no difference between a PAC and a PCM regimen (RRR = 0%; 95% CI -3% to 3%). CONCLUSIONS: PAC and PCM regimens are equally effective if used optimally, though PCM is cheaper. The eradication regimen and its duration should be tailored according to the clinical situation.