J Korean Med Sci.  2014 May;29(5):704-713. 10.3346/jkms.2014.29.5.704.

Meta-Analysis of First-Line Triple Therapy for Helicobacter pylori Eradication in Korea: Is It Time to Change?

• Gong EJ
• Yun SC
• Jung HY
• Lim H
• Choi KS
• Ahn JY
• Lee JH
• Kim DH
• Choi KD
• Song HJ
• Lee GH
• Kim JH

• KMID: 1786114
• DOI: http://doi.org/10.3346/jkms.2014.29.5.704

Abstract

Proton pump inhibitor (PPI)-based triple therapy consisting of PPI, amoxicillin, and clarithromycin, is the recommended first-line treatment for Helicobacter pylori infection. However, the eradication rate of triple therapy has declined over the past few decades. We analyzed the eradication rate and adverse events of triple therapy to evaluate current practices in Korea. A comprehensive literature search was performed up to August 2013 of 104 relevant studies comprising 42,124 patients. The overall eradication rate was 74.6% (95% confidence interval [CI], 72.1%-77.2%) by intention-to-treat analysis and 82.0% (95% CI, 80.8%-83.2%) by per-protocol analysis. The eradication rate decreased significantly from 1998 to 2013 (P < 0.001 for both intention-to-treat and per-protocol analyses). Adverse events were reported in 41 studies with 8,018 subjects with an overall incidence rate of 20.4% (95% CI, 19.6%-21.3%). The available data suggest that the effectiveness of standard triple therapy for H. pylori eradication has decreased to an unacceptable level. A novel therapeutic strategy is warranted to improve the effectiveness of first-line treatment for H. pylori infection in Korea.

Keyword

Helicobacter pylori; Eradication; Triple Therapy

MeSH Terms

Alkylating Agents/therapeutic use
Amoxicillin/therapeutic use
Anti-Bacterial Agents/therapeutic use
Anti-Ulcer Agents/therapeutic use
Clarithromycin/therapeutic use
*Communicable Disease Control
Cytochrome P-450 CYP3A Inhibitors/therapeutic use
*Disease Eradication
*Drug Resistance, Bacterial
Drug Therapy, Combination
Gastritis/microbiology/pathology
Helicobacter Infections/*drug therapy
Helicobacter pylori
Humans
Metronidazole/therapeutic use
Proton Pump Inhibitors/*therapeutic use
Republic of Korea
Tinidazole/therapeutic use
Alkylating Agents
Amoxicillin
Anti-Bacterial Agents
Anti-Ulcer Agents
Clarithromycin
Cytochrome P-450 CYP3A Inhibitors
Metronidazole
Proton Pump Inhibitors
Tinidazole

Figure

• 

  Fig. 1 Flowchart of the study design. RCT, randomized controlled trials.

• 

  Fig. 2 Change in the eradication rate of the standard triple therapy by year. A decreasing trend was seen in the eradication rate during the last 16 yr (P < 0.001 for ITT analysis and P = 0.0003 for PP analysis). ITT, intention-to-treat; PP, per-protocol.

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108. Jo HJ, Lee DH, Kang SJ, Kim MN, Kim SH, Park JM, Choi MS, Jung HC, Song IS, Kim N, et al. Comparison of the efficacy of bismuth containing PPI-based quadruple therapy with PPI-based triple therapy only as first-line treatment for Helicobacter pylori infection. Korean J Gastrointest Endosc. 2008; 37:259–264.

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112. Nam Y, Lee D, Kim N, Jung S, Kim J, Hwang J. The efficacy of adding eupatilin to proton pump inhibitor-based triple therapy for Helicobacter pylori eradication in peptic ulcer in Korea [Abstract]. Helicobacter. 2007; 12:435.

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114. Byun YH, Jo YJ, Kim SC, Lee JS, Shin WY, Park YS, Kim SH, Lee HH, Song MH. Clinical factors that predicts successful eradication of Helicobacter pylori. Korean J Gastroenterol. 2006; 48:172–179.

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116. Lee CH, Lee JK, Kim JW, Park YS. The effectiveness of bismuth and eupatilin along with proton-pump inhibitor-based triple regimen in eradication of Helicobacter pylori [Abstract]. Helicobacter. 2006; 11:392.

117. Kim D. Efficacy of esomeprazole and rabeprazole for Helicobacter pylori eradication in patients with peptic ulcer [Abstract]. Helicobacter. 2006; 11:394.

118. Koo JS, Lee SW, Jung WW, Han WS, Lee JS, Kim MJ, Lee HS, Choi JH, Kim CD, Ryum HS, et al. Helicobacter pylori eradication rate in patients with scar stage of peptic ulcer [Abstract]. Korean J Med. 2005; 69:193.

119. Jung HK, Jin KJ, You MA, Bae KS, Kwon JM, Lee JS, Kim DY, Moon IH. Eradication rate of lansoprazole-based triple therapy in peptic ulcer patients with Helicobacter pylori and efficacy of urea breath test in evaluating Helicobater pylori eradication. Infect Chemother. 2003; 35:154–159.

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121. Choung R, Lee S, Kim M, Jang Y, Kim J, Lee H. The eradication rate of Helicobacter pylori in complicated peptic ulcer patients [Abstract]. Helicobacter. 2003; 8:472.

122. Lee JH, Rhee PL, Hyun JG, Choe WH, Lim YJ, Ahn BH, Lee YW, Kim YH, Kim JJ, Koh KC, et al. Eradication of Helicobacter pylori in patients with S-2 stage duodenal ulcer scar an interim report. Korean J Gastrointest Endosc. 2002; 24:71–75.

123. Choi HS, Kim JH, Kim MC, Jeong TH. Eradication rate of one-week triple therapy for peptic ulcer with Helicobacter pylori and clinical characteristics of patients with failed eradication. J Korean Acad Fam Med. 2002; 23:60–67.

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125. Heo JH, Nam SW, Roe IH, Yang MR, Kim JT, Song IH, Lim CY, Kim JW, Shin JH. Correspondence between H. pylori eradication failure rate and clarithromycin resistance rate [Abstract]. Korean J Gastroenterol. 2002.

126. Kim KO, Chun HJ, Jeong RS, Kim YS, Kim YS, Park CH, Jeen YT, Lee HS, Lee SW, Um S, et al. Comparison of 7-day and 14-day triple therapy in Helicobacter pylori eradication in elderly subjects [Abstract]. Korean J Med. 2002; 63:83.

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128. Kim YJ, Lee SY, Choi SH, Kim YJ. Treatment behavior for the eradication of Helicobacter pylori in peptic ulcer. Korean J Aerosp Environ Med. 2002; 12:28–31.

129. Park JS, Hong SS, Lee YS, Lee E, Myung SJ, Jung HY, Yang SK. Eradication rate for Helicobacter pylori in the elderly. J Korean Geriatr Soc. 2000; 4:138–147.

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