Am Fam Physician. 2007 Sep 1;76(5):633.
TO THE EDITOR: We read with great interest the review on Helicobacter pylori in American Family Physician.1 However, some of the authors' suggestions on the treatment of this condition could be misleading to readers.
The authors reported that a standard triple therapy (proton pump inhibitor, clarithromycin [Biaxin], and amoxicillin) achieved a 90 percent eradication rate following a seven-day regimen (in Table 3) and only an 80 to 86 percent cure rate with the 10- to 14-day therapy (in Table 2).1 However, a large meta-analysis has shown that the 14-day regimen was significantly better than the seven-day therapy.2 Moreover, the success of seven-day triple therapy is decreasing worldwide, with cure rates as low as 25 to 45 percent recently reported.
It has been cited that a one-day quadruple therapy is able to achieve a 95 percent eradication rate (in Table 3).1 Surprisingly, the authors did not report data from other studies in which a very high-dose, one-day quadruple therapy achieved a cure rate as low as 20 to 37 percent.3 It should be noted that a bacterial resistance rate as high as 67 percent has been reported in eradication failure patients.
The authors cited a study in which the eradication of H. pylori was achieved in 81 to 89 percent of patients following a five-day, quadruple therapy including proton pump inhibitors, clarithromycin, amoxicillin, and metronidazole (Flagyl) (in Table 3).1 However, a meta-analysis concluded that: “There were insufficient data to adequately examine treatment success, adverse events and adherence of GNCA [gastric acid inhibitor, a nitroimidazole, clarithromycin, and amoxicillin quadruple therapy] compared with triple therapies.”4
It is astonishing that a review updating H. pylori treatment fails to mention a novel 10-day, sequential therapy that has been tested in more than 1,800 patients; achieved an eradication rate consistently greater than 90 percent in children, adults, and the elderly; and resulted in more effective therapy than standard triple therapy even in patients with clarithromycin resistance.5,6
The cure rate currently achieved by the seven-day triple therapy is far lower than 90 percent, and it is lower than the cure rate achieved with the 14-day regimen. The one-day triple therapy failed to achieve an acceptable eradication rate in several studies.
Author disclosure: Dr. Zullo has no conflicts of interest. Dr. Vaira is a stockholder in Meridian Bioscience, Inc.
1. Ables A, Simon I, Melton ER. Update on Helicobacter pylori treatment. Am Fam Physician. 2007;75:351–8.
2. Calvet X, Garcia N, López T, Gisbert JP, Gené E, Roque M. A meta-analysis of short versus long therapy with a proton pump inhibitor, clarithromycin and either metronidazole or amoxycillin for treating Helicobacter pylori infection. Aliment Pharmacol Ther. 2000;14:603–9.
3. Wermeille J, Cunningham M, Armenian B, Zelger G, Buri P, Merki H, et al. Failure of a 1-day high-dose quadruple therapy for cure of Helicobacter pylori infection. Aliment Pharmacol Ther. 1999;13:173–7.
4. Fischbach LA, van Zanten S, Dickason J. Meta-analysis: the efficacy, adverse events, and adherence related to first-line anti-Helicobacter pylori quadruple therapies. Aliment Pharmacol Ther. 2004;20:1071–82.
5. Zullo A, De Francesco V, Hassan C, Morini S, Vaira D. The sequential therapy regimen for Helicobacter pylori eradication. Gut 2007[Epub in advance of print].
6. Vaira D, Zullo A, Vakil N, Gatta L, Ricci C, Perna F, et al. Sequential therapy versus standard triple-drug therapy for Helicobacter pylori eradication: a randomized trial. Ann Intern Med. 2007;146:556–63.
editor's note: This letter was sent to the authors of “Update on Helicobacter pylori Treatment,” who declined to reply.
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