Korean J Gastroenterol.  2014 Nov;64(5):260-267. 10.4166/kjg.2014.64.5.260.

Ten Day Concomitant Therapy Is Superior to Ten Day Sequential Therapy for Helicobacter pylori Eradication

• Kim SY
• Park DK
• Kwon KA
• Kim KO
• Kim YJ
• Chung JW

• KMID: 2164428
• DOI: http://doi.org/10.4166/kjg.2014.64.5.260

Abstract

BACKGROUND/AIMS
Because the efficacy of standard triple therapy for Helicobacter pylori eradication has declined, new regimens such as sequential therapy (ST) and concomitant therapy (CoCTx) have been introduced. The aim of this study was to compare the efficacy of 10-day ST and 10-day CoCTx for H. pylori eradication.
METHODS
We retrospectively reviewed the medical records of 316 patients with proven H. pylori infection. They were assigned to one of 2 regimens; ST (n=191) consisted of, lansoprazole 30 mg and amoxicillin 1 g for 5 days followed by lansoprazole 30 mg, metronidazole 500 mg, and clarithromycin 500 mg for 5 days, and CoCTx (n=125) consisted of lansoprazole 30 mg, amoxicillin 1 g, metronidazole 500 mg, and clarithromycin 500 mg for 10 days. All drugs were administered twice a day. Bacterial eradication was checked by using a 13C-urea breath test at least 4 weeks after completion of treatment.
RESULTS
The mean age and male to female ratio was 51.74 and 1.03, respectively. Baseline characteristics were not different in both groups. Ten day CoCTx group (94.4%, 118/125) showed better eradication rate than ST group (82.2%, 157/191) (p=0.002). Drug compliances were not statistically different between the two groups (p=0.19). Side effects were more frequently reported in the CoCTx group than in the ST group (p=0.03).
CONCLUSIONS
Ten-day CoCTx was superior to ST in terms of eradicating H. pylori infection. Although the CoCTx producing more side effects than ST, CoCTx can be thought to be a promising alternative to ST as a treatment regimen for H. pylori eradication.

Keyword

Helicobacter pylori; Eradication; First-line regimen

MeSH Terms

Adult
Aged
Amoxicillin/therapeutic use
Anti-Bacterial Agents/*therapeutic use
Breath Tests
Clarithromycin/therapeutic use
Drug Administration Schedule
Drug Therapy, Combination
Female
Helicobacter Infections/diagnosis/*drug therapy
*Helicobacter pylori
Humans
Lansoprazole/therapeutic use
Logistic Models
Male
Metronidazole/therapeutic use
Middle Aged
Proton Pump Inhibitors/*therapeutic use
Retrospective Studies
Risk Factors
Treatment Outcome
Amoxicillin
Anti-Bacterial Agents
Clarithromycin
Lansoprazole
Metronidazole
Proton Pump Inhibitors

Reference

References

1. Hunt RH, Xiao SD, Megraud F, et al. World Gastroenterology Organization. Helicobacter pylori in developing countries. World Gastroenterology Organisation Global Guideline. J Gastrointes-tin Liver Dis. 2011; 20:299–304.

2. McColl KE. Clinical practice. Helicobacter pylori infection. N Engl J Med. 2010; 362:1597–1604.

3. Leodolter A, Kulig M, Brasch H, Meyer-Sabellek W, Willich SN, Malfertheiner P. A meta-analysis comparing eradication, healing and relapse rates in patients with Helicobacter pylori-associated gastric or duodenal ulcer. Aliment Pharmacol Ther. 2001; 15:1949–1958.

4. Hong SS, Jung HY, Choi KD, et al. A prospective analysis of low-grade gastric malt lymphoma after Helicobacter pylori eradication. Helicobacter. 2006; 11:569–573.

5. Fukase K, Kato M, Kikuchi S, et al. Japan Gast Study Group. Effect of eradication of Helicobacter pylori on incidence of meta-chronous gastric carcinoma after endoscopic resection of early gastric cancer: an open-label, randomised controlled trial. Lancet. 2008; 372:392–397.

6. Kim SG, Jung HK, Lee HL, et al. Korean College of Helicobacter and Upper Gastrointestinal Research. Guidelines for the diagnosis and treatment of Helicobacter pylori infection in Korea, 2013 revised edition. Korean J Gastroenterol. 2013; 62:3–26.

7. Chung JW, Lee GH, Han JH, et al. The trends of one-week first-line and second-line eradication therapy for Helicobacter pylori infection in Korea. Hepatogastroenterology. 2011; 58:246–250.

8. Lim JH, Lee DH, Choi C, et al. Clinical outcomes of two-week sequential and concomitant therapies for Helicobacter pylori eradication: a randomized pilot study. Helicobacter. 2013; 18:180–186.

9. Graham DY, Fischbach L. Helicobacter pylori treatment in the era of increasing antibiotic resistance. Gut. 2010; 59:1143–1153.

10. Lee JY, Kim N. Future trends of Helicobacter pylori eradication therapy in Korea. Korean J Gastroenterol. 2014; 63:158–170.

11. Zullo A, Rinaldi V, Winn S, et al. A new highly effective short-term therapy schedule for Helicobacter pylori eradication. Aliment Pharmacol Ther. 2000; 14:715–718.

12. Tong JL, Ran ZH, Shen J, Xiao SD. Sequential therapy vs. standard triple therapies for Helicobacter pylori infection: a meta-analysis. J Clin Pharm Ther. 2009; 34:41–53.

13. Kim JS, Kim BW, Ham JH, et al. Sequential therapy for Helicobacter pylori infection in Korea: systematic review and meta-analysis. Gut Liver. 2013; 7:546–551.

14. Gisbert JP, Calvet X, O'Connor A, Mégraud F, O'Morain CA. Sequential therapy for Helicobacter pylori eradication: a critical review. J Clin Gastroenterol. 2010; 44:313–325.

15. Treiber G, Ammon S, Schneider E, Klotz U. Amoxicillin/metronida-zole/omeprazole/clarithromycin: a new, short quadruple therapy for Helicobacter pylori eradication. Helicobacter. 1998; 3:54–58.

16. Okada M, Oki K, Shirotani T, et al. A new quadruple therapy for the eradication of Helicobacter pylori. Effect of pretreatment with omeprazole on the cure rate. J Gastroenterol. 1998; 33:640–645.

17. Essa AS, Kramer JR, Graham DY, Treiber G. Meta-analysis: four-drug, three-antibiotic, non-bismuth-containing “concomitant therapy” versus triple therapy for Helicobacter pylori eradication. Helicobacter. 2009; 14:109–118.

18. McNicholl AG, Marin AC, Molina-Infante J, et al. Participant Centres. Randomised clinical trial comparing sequential and concomitant therapies for Helicobacter pylori eradication in rou-tine clinical practice. Gut. 2014; 63:244–249.

19. Huang YK, Wu MC, Wang SS, et al. Lansoprazole-based sequential and concomitant therapy for the first-line Helicobacter pylori eradication. J Dig Dis. 2012; 13:232–238.

20. Kang BK, Park SM, Kim BW. New therapeutic strategies against Helicobacter pylori. Korean J Gastroenterol. 2014; 63:146–150.

21. Kim JY, Kim NY, Kim SJ, et al. Regional difference of antibiotic resistance of Helicobacter pylori strains in Korea. Korean J Gastroenterol. 2011; 57:221–229.

22. Wu DC, Hsu PI, Wu JY, et al. Sequential and concomitant therapy with four drugs is equally effective for eradication of H pylori infection. Clin Gastroenterol Hepatol. 2010; 8:36–41.e1.

23. An B, Moon BS, Kim H, et al. Antibiotic resistance in Helicobacter pylori strains and its effect on H. pylori eradication rates in a single center in Korea. Ann Lab Med. 2013; 33:415–419.

24. Maconi G, Parente F, Russo A, Vago L, Imbesi V, Bianchi Porro G. Do some patients with Helicobacter pylori infection benefit from an extension to 2 weeks of a proton pump inhibitor-based triple eradication therapy? Am J Gastroenterol. 2001; 96:359–366.

25. Lai YC, Yang JC, Huang SH. Pre-treatment urea breath test results predict the efficacy of Helicobacter pylori eradication therapy in patients with active duodenal ulcers. World J Gastroenterol. 2004; 10:991–994.

26. Gisbert JP. Sequential or concomitant therapy for Helicobacter pylori eradication? J Clin Gastroenterol. 2010; 44:658–659.

27. Murakami K, Fujioka T, Okimoto T, Sato R, Kodama M, Nasu M. Drug combinations with amoxycillin reduce selection of clarithromycin resistance during Helicobacter pylori eradication therapy. Int J Antimicrob Agents. 2002; 19:67–70.

28. Webber MA, Piddock LJ. The importance of efflux pumps in bacterial antibiotic resistance. J Antimicrob Chemother. 2003; 51:9–11.

29. Graham DY, Lee YC, Wu MS. Rational Helicobacter pylori therapy: evidence-based medicine rather than medicine-based evidence. Clin Gastroenterol Hepatol. 2014; 12:177–86. e3; Discussion e12-13.

30. Chung JW, Jung YK, Kim YJ, et al. Ten-day sequential versus triple therapy for Helicobacter  pylori eradication: a prospective, open-label, randomized trial. J Gastroenterol Hepatol. 2012; 27:1675–1680.

31. Zullo A, Perna F, Hassan C, et al. Primary antibiotic resistance in Helicobacter pylori strains isolated in northern and central Italy. Aliment Pharmacol Ther. 2007; 25:1429–1434.

32. Gisbert JP, Calvet X. Review article: non-bismuth quadruple (concomitant) therapy for eradication of Helicobater pylori. Aliment Pharmacol Ther. 2011; 34:604–617.

33. Treiber G, Wittig J, Ammon S, Walker S, van Doorn LJ, Klotz U. Clinical outcome and influencing factors of a new short-term quadruple therapy for Helicobacter pylori eradication: a randomized controlled trial (MACLOR study). Arch Intern Med. 2002; 162:153–160.

34. Chung JW, Ha M, Yun SC, et al. Meta-analysis: sequential therapy is superior to conventional therapy for Helicobacter pylori infection in Korea. Korean J Gastroenterol. 2013; 62:267–271.

35. Kim SY, Lee SW, Hyun JJ, et al. Comparative study of Helicobacter pylori eradication rates with 5-day quadruple “concomitant” therapy and 7-day standard triple therapy. J Clin Gastroenterol. 2013; 47:21–24.

36. Zullo A, De Francesco V, Hassan C, Morini S, Vaira D. The sequential therapy regimen for Helicobacter pylori eradication: a pooled-data analysis. Gut. 2007; 56:1353–1357.

37. Georgopoulos SD, Xirouchakis E, Martinez-Gonzalez B, et al. Clinical evaluation of a ten-day regimen with esomeprazole, metronidazole, amoxicillin, and clarithromycin for the eradication of Helicobacter pylori in a high clarithromycin resistance area. Helicobacter. 2013; 18:459–467.

38. Chung JW, Lee JH, Jung HY, et al. Second-line Helicobacter pylori eradication: a randomized comparison of 1-week or 2-week bis-muth-containing quadruple therapy. Helicobacter. 2011; 16:289–294.

39. Huang JQ, Hunt RH. Treatment after failure: the problem of “n-on-responders”. Gut. 1999; 45(Suppl 1):I40–I44.

40. Cho DK, Park SY, Kee WJ, et al. The trend of eradication rate of Helicobacter pylori infection and clinical factors that affect the eradication of first-line therapy. Korean J Gastroenterol. 2010; 55:368–375.

41. Labenz J, Leverkus F, Börsch G. Omeprazole plus amoxicillin for cure of Helicobacter pylori infection. Factors influencing the treatment success. Scand J Gastroenterol. 1994; 29:1070–1075.

42. Gisbert JP, Marcos S, Gisbert JL, Pajares JM. Helicobacter pylori eradication therapy is more effective in peptic ulcer than in non-ulcer dyspepsia. Eur J Gastroenterol Hepatol. 2001; 13:1303–1307.

43. Suzuki T, Matsuo K, Ito H, et al. Smoking increases the treatment failure for Helicobacter pylori eradication. Am J Med. 2006; 119:217–224.

44. Bardhan KD, Graham DY, Hunt RH, O'Morain CA. Effects of smoking on cure of Helicobacter pylori infection and duodenal ulcer recurrence in patients treated with clarithromycin and omeprazole. Helicobacter. 1997; 2:27–31.

45. De Francesco V, Zullo A, Margiotta M, et al. Sequential treatment for Helicobacter pylori does not share the risk factors of triple therapy failure. Aliment Pharmacol Ther. 2004; 19:407–414.