One-week ranitidine bismuth citrate, amoxicillin and metronidazole triple therapy for the treatment of Helicobacter pylori infection in Chinese

Bismuth supplements as the first-line regimen for Helicobacter pylori eradication therapy: Systemic review and meta-analysis

BACKGROUND AND AIMS

An increase in the use of antibiotics leads to increased antibiotic resistance of Helicobacter pylori (H pylori). Consequently, it has been considered that the first-line standard regimen should be changed. The main purpose of this study was to evaluate the efficacy of nonantibiotic (bismuth) supplements as a first-line regimen for H pylori eradication.

METHODS

We searched PubMed, EMBASE, CINAHL, and the Cochrane Library databases for randomized controlled trials (RCTs) reported in English and undertaken up until August 2018. A meta-analysis of all randomized controlled trials comparing bismuth supplements with non-bismuth-containing regimens in H pylori eradication was performed. RCTs of classic bismuth-containing quadruple therapy as a first-line regimen were excluded.

RESULTS

We identified twenty-five randomized trials (3990 patients), and the total H pylori eradication rate, according to per protocol analyzed, was 85.8%. The odds ratio was 1.83 (95% confidence interval (CI). 1.57-2.13). Among these RCTs, there were 7 RCTs for bismuth add-on therapy, and the odds ratio was 2.81 (95% CI. 2.03-3.89). When the studies were performed in a high clarithromycin resistance area (≥15%) or included patients with clarithromycin resistance, bismuth-containing regimens were superior to non-bismuth regimens. Moreover, the incidence of total side effects was insignificant.

CONCLUSIONS

Bismuth supplements as a first-line regimen could be effective, with bismuth add-on regimens being the most effective. Particularly, bismuth supplements showed the potential efficacy for clarithromycin-resistant strains and would be the most viable alternative in clinical practice.

Adverse events with bismuth salts for Helicobacter pylori eradication: systematic review and meta-analysis

AIM

To assess the safety of bismuth used in Helicobacter pylori (H pylori) eradication therapy regimens.

METHODS

We conducted a systematic review and meta-analysis. MEDLINE and EMBASE were searched (up to October 2007) to identify randomised controlled trials comparing bismuth with placebo or no treatment, or bismuth salts in combination with antibiotics as part of eradication therapy with the same dose and duration of antibiotics alone or, in combination, with acid suppression. Total numbers of adverse events were recorded. Data were pooled and expressed as relative risks with 95% confidence intervals (CI).

RESULTS

We identified 35 randomised controlled trials containing 4763 patients. There were no serious adverse events occurring with bismuth therapy. There was no statistically significant difference detected in total adverse events with bismuth [relative risk (RR) = 1.01; 95% CI: 0.87-1.16], specific individual adverse events, with the exception of dark stools (RR = 5.06; 95% CI: 1.59-16.12), or adverse events leading to withdrawal of therapy (RR = 0.86; 95% CI: 0.54-1.37).

CONCLUSION

Bismuth for the treatment of H pylori is safe and well-tolerated. The only adverse event occurring significantly more commonly was dark stools.

Efficacy of a new therapeutic regimen versus two routinely prescribed treatments for eradication of Helicobacter pylori: a randomized, double-blind study of doxycycline, co-amoxiclav, and omeprazole in Iranian patients

This study compared a new regimen (group A: doxycycline, co-amoxiclav, omeprazole) and two routinely prescribed regimens (group B: amoxicillin, omeprazole, furazolidone, bismuth; group C: amoxicillin, clarithromycin, omeprazole) to find an acceptable first-line treatment option for Helicobacter pylori. The study population consisted of 189 patients who referred to our clinic to undergo endoscopy due to ulcer-like dyspepsia. The H. pylori eradication rate was 68% in group A, 56% in group B, and 70% in group C according to per-control analysis. There was no statistically significant difference in H. pylori eradication between groups A and B (P = 0.187), groups A and C (P = 0.857), and groups B and C (P = 0.15). In conclusion, although none of the three eradication regimens can be recommended as a first-line eradication treatment, the new regimen is at least as effective and probably better tolerated than the two routinely applied regimens.

Adverse events with bismuth salts for Helicobacter pylori eradication: Systematic review and meta-analysis

AIM: To assess the safety of bismuth used in Helicobacter pylori (H pylori) eradication therapy regimens.

METHODS: We conducted a systematic review and meta-analysis. MEDLINE and EMBASE were searched (up to October 2007) to identify randomised controlled trials comparing bismuth with placebo or no treatment, or bismuth salts in combination with antibiotics as part of eradication therapy with the same dose and duration of antibiotics alone or, in combination, with acid suppression. Total numbers of adverse events were recorded. Data were pooled and expressed as relative risks with 95% confidence intervals (CI).

RESULTS: We identified 35 randomised controlled trials containing 4763 patients. There were no serious adverse events occurring with bismuth therapy. There was no statistically significant difference detected in total adverse events with bismuth [relative risk (RR) = 1.01; 95% CI: 0.87-1.16], specific individual adverse events, with the exception of dark stools (RR = 5.06; 95% CI: 1.59-16.12), or adverse events leading to withdrawal of therapy (RR = 0.86; 95% CI: 0.54-1.37).

CONCLUSION: Bismuth for the treatment of H pylori is safe and well-tolerated. The only adverse event occurring significantly more commonly was dark stools.

Systematic review and meta-analysis: proton pump inhibitor vs. ranitidine bismuth citrate plus two antibiotics in Helicobacter pylori eradication

OBJECTIVE

To systematically review the Helicobacter pylori eradication efficacy with ranitidine bismuth citrate (RBC) and two antibiotics, and to conduct a meta-analysis of randomized clinical trials comparing the efficacy of proton pump inhibitor (PPI) vs. RBC with two antibiotics for 1 week.

SELECTION OF STUDIES

Studies evaluating RBC plus two antibiotics were considered. For the meta-analysis, randomized controlled trials comparing PPI vs. RBC plus two antibiotics for 1 week were included.

SEARCH STRATEGY

Electronic and manual bibliographical searches. Assessment of study quality and data extraction: Independently done by two reviewers.

DATA SYNTHESIS

'Intention-to-treat' eradication rate. Meta-analysis was performed, combining the odds ratios (OR) of the individual studies. Subanalysis: Depending on the type of antibiotics and the quality of the studies.

RESULTS

Mean H. pylori eradication with 7-day RBC-clarithromycin-amoxicillin, RBC-clarithromycin-nitroimidazole, and RBC-amoxicillin-nitroimidazole was 83%, 86%, and 71%, respectively. The meta-analysis showed comparable efficacy with RBC and PPI when they were combined with clarithromycin and amoxicillin (OR = 1.11; 95% CI = 0.88-1.40), or with amoxicillin and metronidazole (OR = 0.92; 95%CI = 0.60-1.41). However, when comparing PPI vs. RBC plus clarithromycin and a nitroimidazole, higher cure rates with RBC than with PPI were demonstrated (OR = 1.65; 95% CI = 1.15-2.37).

CONCLUSION

The efficacy of RBC and PPI-based triple regimens were comparable when using the clarithromycin-amoxicillin or the amoxicillin-metronidazole combination. However, RBC seems to have a higher efficacy than PPI when clarithromycin and a nitroimidazole are the antibiotics prescribed. Therefore, if one prefers to use the clarithromycin-nitroimidazole regimen, RBC should be used instead of a PPI.

Low-dose rabeprazole, amoxicillin and metronidazole triple therapy for the treatment of Helicobacter pylori infection in Chinese patients

BACKGROUND

Rabeprazole in combination with amoxicillin and metronidazole (RAM) has been shown to be an effective second-line treatment of Helicobacter pylori infection. The effects were compared of 7-day low-dose and high dose rabeprazole in RAM for the primary treatment of H. pylori infection in Chinese patients.

METHODS

Helicobacter pylori-positive dyspeptic patients were randomized to receive either (i) rabeprazole 10 mg, amoxicillin 1000 mg and metronidazole 400 mg (RAM-10) or (ii) high-dose rabeprazole 20 mg, amoxicillin 1000 mg and metronidazole 400 mg (RAM-20), each given twice daily for 7 days. Helicobacter pylori eradication was confirmed by (13)c-urea breath test 5 weeks after stopping medications. side-effects of treatments were documented.

RESULTS

A total of 120 patients were eligible for analysis. By intention-to-treat and per-protocol analysis, the eradication rates were 83% and 86% in the RAM-10 group and 75% and 76% in the RAM-20 group, respectively (P = 0.26 and P = 0.17). Both regimens were well-tolerated and compliance was >98% in both groups.

CONCLUSIONS

Low-dose rabeprazole in combination with amoxicillin and metronidazole is an effective, economical and well-tolerated therapy for the treatment of H. pylori infection in Chinese population.

First-line eradication therapy for Helicobacter pylori in primary health care based on antibiotic resistance: results of three eradication regimens

AIM

To determine the efficacy of three Helicobacter pylori eradication regimens and factors affecting the eradication results in Finland.

METHODS

A total of 342 H. pylori-positive adult patients from primary health care referred for gastroscopy at 23 centres in different parts of Finland were randomized to receive either (i) lansoprazole 30 mg b.d., amoxicillin 1 g b.d. and metronidazole 400 mg t.d.s. (LAM), (ii) lansoprazole 30 mg b.d., amoxicillin 1 g b.d. and clarithromycin 500 mg b.d. (LAC), or (iii) ranitidine bismuth citrate 400 mg b.d., metronidazole 400 mg t.d.s. and tetracycline 500 mg q.d.s. (RMT). A (13)C-urea breath test was performed 4 weeks after therapy.

RESULTS

The eradication result could be assessed in 329 cases. Intention-to-treat cure rates of LAM, LAC, and RMT were 78, 91 and 81%. The difference was significant between LAM and LAC (P = 0.01) and between LAC and RMT (P = 0.04). The eradication rates in cases with metronidazole-susceptible vs. -resistant isolates were for LAM 93% vs. 53% (P = 0.00001), for LAC 95% vs. 84%, and for RMT 91% vs. 67% (P = 0.002). Previous antibiotic use, smoking, and coffee drinking reduced the efficacy of therapy.

CONCLUSIONS

In unselected patients in primary health care, LAC was the most effective first-line eradication.

Treatment of Helicobacter pylori infection

Review of the recently published data on Helicobacter pylori management highlights various interesting aspects. Current H. pylori eradication guidelines generally suggest a noninvasive 'test and treat' strategy for all dyspeptic patients with certain age limits depending on the local gastric neoplasia risk. According to the 'Maastricht 2-2000 Consensus Report' treatment should be thought of as a 'package' considering first- and second-line eradication therapies together. Various centres have published their results using novel antimicrobial formulations and 'rescue' and 'sequential' therapies. Review suggests that care at the specialist level remains a challenge and guidelines are deficient particularly as regards the selection and duration of eradication therapies. Results indicate that differences for CYP2C19 genotype and the selection of proton pump inhibitors have no significant role in determining eradication rates whereas antibiotic resistance and socio-economic factors play a variable role according to different geographical areas. Compliance remains an important factor in determining clinical outcome at the primary and secondary levels worldwide.