Recommendations for the treatment of H. pylori infection are outlined in the American College of Gastroenterology (ACG) guidelines, which provide both first-line and alternative therapies. Generally, first-line treatment may include one of the following regimens:
- Clarithromycin, a proton pump inhibitor (PPI) and amoxicillin or metronidazole (triple therapy); recommended in regions with <15% clarithromycin resistance
- Bismuth salt, tetracycline, and metronidazole plus a PPI (bismuth quadruple therapy); for use in areas with high resistance rates or in those with previous macrolide exposure
- Clarithromycin, PPI, amoxicillin, and metronidazole (concomitant therapy); while effective, data for this regimen is lacking
However, in some cases, contraindications or initial treatment failure may make it challenging to treat certain patients with H. pylori infection. In their review, the authors looked at some of these challenges and provided first-line and alternative regimens for treatment based on an extensive literature search using the PubMed database. Particularly, they focused on the following clinical scenarios: patients with penicillin allergies, patients at risk for QTc-interval prolongation, pregnant and breastfeeding patients, and elderly patients.
In patients with penicillin allergies, clarithromycin triple therapy with metronidazole (when resistance is not a concern) or bismuth quadruple therapy (preferred in patients with previous macrolide exposure or if there is concern of macrolide resistance) were recommended as first-line therapies as both were deemed to be equally effective; alternative regimens in these patients included levofloxacin-based triple therapy (preferred) or rifabutin-based triple or quadruple therapy, both excluding amoxicillin.
As for patients at risk for QTc-interval prolongation, bismuth quadruple therapy was recommended as the treatment of choice. Alternative regimens, which were all found to be similarly effective, included amoxicillin-based dual therapy (preferred due to lower pill burden and decreased risk of drug interactions and adverse reactions), rifabutin-based triple or quadruple therapy, or triple therapy with amoxicillin, metronidazole, and a PPI, according to the review.
In elderly patients, recommendations were similar to those for the general population, however with increased monitoring; sequential therapy (amoxicillin and rabeprazole for 5 days followed by metronidazole, clarithromycin, and rabeprazole for 5 more days) was recommended as an alternative regimen.
As most of the agents included in these regimens carry some fetal risk, the authors concluded that in women who are pregnant or breastfeeding and have no or mild symptoms, treatment of H. pylori infection should be postponed. In patients with hyperemesis gravidarum, the benefits and risks of treatment should be weighed, and if pursued, therapy should be limited to 7 days to minimize risk. In the first trimester, triple therapy with amoxicillin, metronidazole, and a PPI was recommended while in the second and third trimester, or during breastfeeding, clarithromycin triple therapy with amoxicillin should be offered, according to the authors.
“Selecting an appropriate regimen based on patient allergies and coexisting conditions is crucial to ensuring patient safety without compromising treatment efficacy,” the authors concluded. They added that “In the absence of any mitigating solutions, providers should carefully consider the risks versus benefits of available options when selecting treatment regimens in these common but challenging scenarios.”
Nguyen, C. T., Davis, K. A., Nisly, S. and Li, J. (2019), Treatment of Helicobacter pylori in Special Patient Populations. Pharmacotherapy. doi:10.1002/phar.2318.
This article originally appeared on MPR