A pilot study evaluating sequential administration of a PPI-amoxicillin followed by a PPI-metronidazole-tetracycline in Turkey

Standard triple therapy in Helicobacter pylori eradication in Turkey: Systematic evaluation and meta-analysis of 10-year studies

BACKGROUND/AIMS

This study aims at evaluating the mean eradication rate by a systematic compilation of the studies which involved the standard triple therapy (STT) in first-line Helicobacter pylori (Hp) eradication in Turkey over a period of 10 years between 2004 and 2013 using the meta-analysis method.

MATERIALS AND METHODS

The systematic compilation and meta-analysis were carried out according to the PRISMA standards defined in the Cochrane handbook. The results of full-text studies published in national and international journals in English and Turkish languages on Turkish population in a period of 10 years, from 2004 to 2013, are included in this study. The studies include open-label trials, controlled trials, treatment arms, and case series that included a triple therapy regimen consisting of standard doses of a proton pump inhibitor (PPI; omeprazole 20 mg BID, lansoprazole 30 mg BID, pantoprazole 40 mg BID, esomeprazole 40 mg BID, or rabeprazole 20 mg BID) along with clarithromycin 500 mg BID and amoxicillin 1 g BID for 7-14 days. They were scanned electronically via the search engines Google Scholar, PubMed, and the Turkish Medicine Index using specific keywords. The related keywords used were Turkey, Helicobacter pylori, infection, standard triple treatment, first-line therapy, eradication, omeprazole, lansoprazole, pantoprazole, rabeprazole, esomeprazole, clarithromycin, and amoxicillin. Studies carried out with adults were included in the evaluation. The publication year of the studies and the included number of patients, their age, gender, treatment duration (7, 10, and 14 days), and PPIs used were evaluated by two separate gastroenterologists and biostatisticians. Studies that used at least one reliable method (histology, urea breath test (UBT), or Helicobacter pylori stool antigen (HpSA) test) four weeks after completing the treatment for the control of Hp eradication were included. Only naive patients were accepted, and patients who had previously received eradication treatment were excluded. The effectiveness of the Hp eradication was analyzed using an intention-to-treat (ITT) or per-protocol (PP) analysis.

RESULTS

The STT regime of 45 studies complying with the inclusion criteria was evaluated. A total of 3715 patients were included in the study. Of the 3010 patients whose gender information was available, 55% were women and 45% were men; the weighted age average given explicitly in the studies was 42.14±0.67. The treatment lasted for 14 days in 42 studies, for 7 days in six studies, and for 10 days in 1 study. The eradication rates evaluated according to the ITT and PP analyses were 60% (95% CI: 56%-63%) and 57% (95% CI: 51%-62%), respectively. The rates for 7 days of treatment were 57% (95% CI: 46%-68%) and 60% (95% CI: 51%-67%) and for 14 days of treatment were 60% (95% CI: 56%-63%) and 56% (95% CI: 50%-62%), respectively. The ITT eradication rate of the only 10-day study was 78% (95% CI: 66%-86%). In the meta-regression analysis, the treatment duration, PPI, age, and gender ratio (women/men) used for the ITT analysis had no effect. The gender ratio and age were not considered in this analysis because they were not clearly stated in studies using the PP analysis. The duration of treatment and the PPI used had no effect.

CONCLUSION

A systematic meta-analysis of studies conducted during the period 2004-2013 in Turkey revealed that the rate of first-line Hp eradication using STT was unacceptably low, and the duration of treatment and PPI used made no difference.

Comparison of three different regimens against Helicobacter pylori as a first-line treatment: A randomized clinical trial

Treatments with bismuth-containing quadruple therapy (QT), sequential therapy (ST), or concomitant therapy (CT) have been proposed as empirical first-line regimens for Helicobacter pylori. We compared the efficacy and tolerability of 10 days bismuth-containing quadruple QT, 10 days ST, and 10 days CT with as first-line treatments for H. pylori in a randomized crossover study. The subjects were randomly divided into three groups. The first 130 patients were treated with rabeprazole, bismuth potassium citrate, metronidazole, and tetracycline for 10 days. The second 130 patients in the sequential group were treated with rabeprazole and amoxicillin for 5 days, and then rabeprazole, clarithromycin, and metronidazole for an additional 5 days. The last 130 patients in the concomitant group were treated with rabeprazole, amoxicillin, clarithromycin, and metronidazole for 10 days. H. pylori eradication was confirmed by urea breath test at 6 weeks. The primary outcome was eradication rates of first-line treatment by intention to treat and per protocol (PP) analyzes. There was no difference between the average ages and the male/female ratio of the groups. The PP analysis was performed on 121, 119, and 118 patients in the QT, ST, and CT groups, respectively. In the PP analysis, the successful eradication 94.2% (114/121), 95.0% (113/119), and 95.8% (113/118) the QT, ST, and CT groups, respectively. There was no significant difference among the three groups (p = 0.86). 10 days QT, ST, and CT are highly effective as empirical first-line therapies for H. pylori in the region with high clarithromycin resistance.

Meta-analysis: Is combination of tetracycline and amoxicillin suitable for Helicobacter pylori infection?

AIM: To access the efficacy of combination with amoxicillin and tetracycline for eradication of Helicobacter pylori (H. pylori), thus providing clinical practice guidelines.

METHODS: PubMed, EMBASE, Cochrane Central Register of Controlled Trials, Science Citation Index, China National Knowledge Infrastructure, Wanfang, and Chinese Biomedical Literature databases and abstract books of major European, American, and Asian gastroenterological meetings were searched. All clinical trials that examined the efficacy of H. pylori eradication therapies and included both tetracycline and amoxicillin in one study arm were selected for this systematic review and meta-analysis. Statistical analysis was performed with Comprehensive Meta-Analysis Software (Version 2). Subgroup, meta-regression, and sensitivity analyses were also carried out.

RESULTS: Thirty-three studies met the inclusion criteria. The pooled odds ratio (OR) was 0.90 (95%CI: 0.42-1.78) for quadruple therapy with amoxicillin and tetracycline vs other quadruple regimens, and total eradication rates were 78.1% by intention-to-treat (ITT) and 84.5% by per-protocol (PP) analyses in the experimental groups. The pooled eradication rates of 14-d quadruple regimens with a combination of amoxicillin and tetracycline were 82.3% by ITT and 89.0% by PP, and those of 10-d regimens were 84.6% by ITT and 93.7% by PP. The OR by ITT were 1.21 (95%CI: 0.64-2.28) for triple regimens with amoxicillin and tetracycline vs other regimens and 1.81 (95%CI: 1.37-2.41) for sequential treatment with amoxicillin and tetracycline vs other regimens, respectively.

CONCLUSION: The effectiveness of regimens employing amoxicillin and tetracycline for H. pylori eradication may be not inferior to other regimens, but further study should be necessary.

Modified sequential therapy regimens for Helicobacter pylori eradication: a systematic review

BACKGROUND

Different modified sequential therapies have been proposed for Helicobacter pylori eradication. However, the efficacy of these regimens is controversial.

METHODS

We performed a systematic review of the literature and pooled-data analysis to assess: (a) the efficacy of different modified sequential therapies for H. pylori eradication, (b) the eradication rates achieved by these regimens as compared to either standard triple therapies or standard sequential regimen when available.

RESULTS

Overall 21 trials met inclusion criteria. The most used modified sequential therapy was the seven plus seven tetracycline-based regimen which achieved an overall 73.3% eradication rate (6 trials). Such therapy was more effective than the 14-day triple therapy (77.2% vs. 63.6%; 3 trials). The most used five plus five levofloxacin-based sequential therapy achieved a 95.8% and 90% cure rates when 250 mg and 500 mg levofloxacin twice daily were used, respectively. These success rates were higher as compared to that of either standard sequential or triple therapies. Other modified sequential therapies did not achieved acceptably high cure rates. Contradictory results emerged from 2 studies assessing the efficacy of a levofloxacin-based sequential regimen as a second-line therapy.

CONCLUSIONS

Both levofloxacin- and tetracycline-based sequential therapies have been proved to be more effective than standard triple therapies, confirming that the 'sequential' administration of drugs is a successful therapeutic procedure for H. pylori infection.

Efficacy of a modified sequential therapy including bismuth subcitrate as first-line therapy to eradicate Helicobacter pylori in a Turkish population

BACKGROUND

Eradication rates of Helicobacter pylori with standard triple therapy are not satisfactory. Sequential therapy is an alternative method to overcome this problem.

OBJECTIVES

The aim of this study was to assess efficacy of a modified sequential therapy with the addition of a bismuth preparation, as first-line treatment in the eradication of H. pylori infection.

MATERIALS AND METHODS

One hundred and forty-two H. pylori-positive patients were included in the study. Patients were given a 14-day sequential therapy program consisting of pantoprazole, 40 mg (b.i.d. for 14 days); colloidal bismuth subcitrate, 300 mg 4 (two tablets before breakfast and dinner, for 14 days); amoxicillin, 1 g (b.i.d.for the first 7 days); tetracycline, 500 mg (q.i.d. for the second 7 days); and metronidazole, 500 mg (t.i.d. for the second 7 days). Eradication was tested by urea breath test (UBT) 6 weeks after completion of treatment.

RESULTS

Of the 142 patients included, 131 completed the study. "Per-protocol" and "intention-to-treat" analyses revealed high eradication rates in this group (92.0-95% CI, 87.2-96.8%, and 81.0-95% CI, 74.5-87.4%, respectively). There was no relation to sex and age with this modified sequential therapy. Compliance was satisfactory (11 patients - four women and seven men were unavailable for follow-up), and side effects were minimal (six patients had to stop treatment - metronidazole-related facial swelling and numbness on the face and hands in two patients; tetracycline-related fever and epigastric pain and nausea and vomiting in two patients; and amoxicillin-related diarrhea and vaginal discharge in two patients). These side effects were reversible and resolved after the cessation of the related medication.

CONCLUSIONS

This 14-day modified sequential treatment, including bismuth, achieves a significantly high eradication rates in patients with H. pylori infection, with five satisfactory patient compliance and minor side effects.

Ten-day sequential versus triple therapy for Helicobacter pylori eradication: a prospective, open-label, randomized trial

BACKGROUND AND AIM

Increased resistance of Helicobacter pylori to antibiotics has increased the need to develop new first-line treatments for H. pylori. We have prospectively evaluated 10-day sequential versus conventional triple therapy in peptic ulcer patients.

METHODS

One hundred and fifty-nine patients with peptic ulcer diseases were prospectively randomized to receive 10 days of lansoprazole, amoxicillin, and clarithromycin (conventional triple therapy) or 5 days of lansoprazole and amoxicillin followed by 5 days of lansoprazole, clarithromycin, and metronidazole (sequential therapy). Post-treatment H. pylori status was determined by the (13) C-urea breath test. Eradication rates, antibiotic resistance rates by agar dilution method, drug compliance, and side-effects were compared.

RESULTS

The intention-to-treat eradication rates were 75.9% (95% CI 66.5-85.3%, 60/79) in the sequential therapy group and 58.7% (95% CI 47.9-69.5%, 47/80) in the conventional triple therapy group (P = 0.01), while the per-protocol eradication rates were 86.8% (95% CI 78.7-94.8%, 59/68) and 67.6% (95% CI 56.5-78.7%, 46/68) (P = 0.01), respectively. Compliance and side-effects were similar in the two groups. Culture of H. pylori showed that 18.2% were resistant to clarithromycin, 41.9% to metronidazole. Dual resistance to both antibiotics was 9.6%.

CONCLUSIONS

Although 10-day sequential therapy yielded a higher H. pylori eradication rate than 10-day conventional triple therapy, the sequential therapy protocol did not result in a sufficiently satisfactory eradication rate. This might be related to the higher antibiotics resistance rate especially to dual resistance. More effective regimens are needed to overcome antibiotic resistance in Korea.

Comparison of two different treatment protocols in Helicobacter pylori eradication

BACKGROUND

The prevalence of Helicobacter pylori (H pylori) in Turkey is high and eradication rates are low. As a result, alternative treatment strategies are required.

OBJECTIVES

To evaluate the status of H pylori eradication in Turkey by comparing the results of this study to other studies reported in the literature.

METHODS

Two hundred and eighty-two patients diagnosed with H pylori were included in this study. Patients were randomized into two groups. The first group consisted of 138 patients receiving 30 mg lansoprazole bid, amoxicillin 1 g bid, and clarithromycin 500 mg bid for 14 days. The second group consisted of 144 patients who received lansoprazole 30 mg bid and amoxicillin 1 g bid for seven days, followed by metronidazole 500 mg bid, tetracycline 500 mg qid, and lansoprazole 30 mg bid for an additional seven days.

RESULTS

H pylori eradication rates in the first group were 53.6% according to intention-to-treat analysis, and 52.5% according to per protocol analysis. In the second group, eradication rates were 72.2% per intention-to-treat analysis and 77.6% as per protocol analysis. H pylori eradication rates in the second group were significantly higher than the first group (P=0.001, P<0.05), whereas the incidence of adverse events in the second group was significantly lower (P=0.048, P<0.05).

CONCLUSION

This study found a significant difference in eradication rates between the traditional triple therapy and modified sequential therapy groups. As a result, modified sequential therapy shows promise as an alternative treatment.

Effect of Helicobacter pylori eradication on insulin resistance, serum lipids and low-grade inflammation

BACKGROUND/AIM

Many studies have revealed a close relationship between Helicobacter pylori (HP) infection and insulin resistance. The aim of this study was to investigate the effects of HP eradication on insulin resistance, serum lipids and low-grade inflammation.

MATERIALS AND METHODS

This was a prospective, open-label, single-center study which consisted of 159 patients. The patients with HP infection received a 14-day sequential regimen. A HOMA-IR (homeostasis model assessment of insulin resistance) level was used to assess insulin resistance.

RESULTS

Eighty-eight patients with HP infection and seventy-one patients without HP infection were studied. HOMA-IR, total cholesterol (TC), triglyceride (TG), LDL cholesterol (LDL-C) and C reactive protein (CRP) levels were significantly higher and HDL-cholesterol (HDL-C) levels were significantly lower in patients with HP infection compared to the patients without HP infection (P<0.05). The HP eradication rates with a sequential regimen in dyspeptic patients were 53.4%. Six weeks after the end of eradication therapy, the mean fasting insulin, HOMA-IR, TC, TG, LDL-C, and CRP levels in patients with successful eradication were significantly decreased from the pretreatment levels (P<0.05) and HDL-C level was significantly increased from the pretreatment levels (P<0.05). The mean fasting insulin, HOMA-IR, TC, TG, LDL-C, CRP levels and HDL-C levels in patients with unsuccessful eradication were not significantly changed from pretreatment levels (P<0.05).

CONCLUSION

This study showed beneficial effects of HP eradication on insulin resistance, atherogenic lipid abnormalities and low-grade inflammation. The results suggest that HP eradication may prevent coronary artery disease and metabolic syndrome.

Comparison of the efficacy of the two tetracycline-containing sequential therapy regimens for the eradication of Helicobacter pylori: 5 days versus 14 days amoxicillin

AIM

To compare the efficacy of 14-day and 5-day amoxicillin treatment on the eradication rate during tetracycline containing sequential H. pylori therapy, and also to compare the eradication rate of this regimen with those used in similar studies performed in Turkey.

METHOD

This study included 112 patients infected with H. pylori that were randomized into 2 groups. In group A, patients (n = 56) received pantoprazole (40 mg BID) and amoxicillin (1 g BID) for 5 days, followed by pantoprazole (40 mg BID), tetracycline (500 mg QID), and metronidazole (500 mg TID) for the remaining 9 days. In group B, patients (n = 56) received pantoprazole (40 mg BID) and amoxicillin (1 g BID) for 5 days, followed by pantoprazole (40 mg BID), tetracycline (500 mg QID), metronidazole (500 mg TID), and amoxicillin (1 g BID) for the remaining 9 days. Eradication rates were calculated using both intention-to-treat (ITT) and per-protocol (PP) analyses.

RESULTS

In all, 112 patients were subjected to ITT analysis and 109 patients completed the study. In group A, H. pylori eradication was achieved in 46 (82.1%) of the 56 patients included in the ITT analysis and in 46 (83.6%) of the 55 patients included in the PP analysis. In group B, H. pylori eradication was achieved in 44 (78.57%) of the 56 patients included in the ITT analysis and in 44 (81.48%) of the 54 patients included in the PP analysis (Table 2). The eradication rates were not statistically significant between the 2 groups (p > .005).

CONCLUSION

Extended duration of amoxicillin treatment during the entire tetracycline containing sequential therapy period did not improve the H. pylori eradication rate. As a consequence, sequential therapy using 5-day amoxicillin is an acceptable first-line therapy option for the eradication of H. pylori in Turkey.

The modified sequential treatment regimen containing levofloxacin for Helicobacter pylori eradication in Turkey

BACKGROUND

Eradication rates of Helicobacter pylori have declined to unacceptable levels in recent years. New and effective treatment options are warranted both as a first and second line treatment.

AIM

To test an effectiveness of modified sequential therapy with levofloxacin for H. pylori eradication in Turkey.

MATERIAL AND METHODS

Helicobacter pylori infected dyspeptic patients were included to the study. Subjects were treated with modified sequential therapy consisting of rabeprazole 20 mg b.i.d. and amoxicillin 1 g b.i.d., for 7 days followed by rabeprazole 20 mg b.i.d, levofloxacin 500 mg q.d. and metronidazole 500 mg b.i.d for the remaining 7 days.

RESULTS

Sixty-three treatment naive patients and 37 previous treatment failures were enrolled to the study (59 F, 41 M, age: 21-80 years). There was five drop out. Helicobacter pylori eradication was achieved in 80 patients, intention-to-treat (ITT): 80% (95% CI: 71-87%) and per-protocol (PP): 84.2% (95% CI: 75-91%), totally. In treatment naive patients ITT and PP eradication rates were 82.5% (95% CI: 71-91%), and 86.7% (95% CI: 75-94%), respectively. As a second line treatment eradication was successful in ITT 75.7%.(95% CI: 59-88%), and PP 80% (95% CI: 63-92%).Mild side effects were reported by 8 patients (8.4%).

CONCLUSIONS

Sequential therapy using "rabeprazole and amoxicillin 7 days followed by rabeprazole, metronidazole and levofloxacin for 7 days" is a new regimen with acceptable eradication rates in naïve patients in Turkey. Further modifications in the dose or duration of this new sequential therapy might increase its effectiveness as both first and second line treatment.

Triple or quadruple tetracycline-based therapies versus standard triple treatment for Helicobacter pylori treatment

BACKGROUND

Our aim was to compare lansoprazole-tetracycline-metranidazole (LTM) as first-line treatment with the classical lansoprazole-amoxicillin-clarithromycin (LAC) and bismuth-containing quadruple treatments.

PATIENTS AND METHODS

This prospective, single-center, randomized study included 464 consecutive Helicobacter pylori-positive patients with dyspeptic symptoms. A total of 415 patients completed the study. The patients were allocated into 4 study groups using random sampling numbers as follows-LAC group: lansoprazole 30 mg twice daily, amoxicillin 1000 mg twice daily, and clarithromycin 500 mg twice daily for 14 days; BLTM group: bismuth subcitrate 300 mg 4 times a day, lansoprazole 30 mg twice daily, tetracycline 500 mg 4 times a day, and metronidazole 500 mg twice daily for 10 days; RBLTM group: ranitidine bismuth citrate 400 mg twice daily, lansoprazole 30 mg twice daily, tetracycline 500 mg 4 times a day, and metronidazole 500 mg twice daily for 10 days; and LTM group: lansoprazole 30 mg twice daily, tetracycline 500 mg 4 times a day, and metronidazole 500 mg twice daily for 10 days.

RESULTS

The per protocol H. pylori eradication rate in LAC, BLTM, RBLTM, and LTM groups were 37 of 104 (35.6%), 56 of 102 (54.9%), 67 of 104 (64.4%), and 63 of 105 (60%), respectively. The intention-to-treat eradication rate was 37 of 113 (32.7%) in LAC, 56 of 119 (47.1%) in BLTM, 67 of 117 (57.3%) in RBLTM, and 63 of 115 (54.8%) in LTM group. The BLTM, RBLTM, and LTM treatment groups achieved a significantly better eradication rate than the LAC treatment group (P < 0.001). There was not any significant statistical difference between the groups of BLTM, RBLTM, and LTM.

CONCLUSION

LTM treatment group achieved a significantly better eradication rate than the LAC treatment group. The success ratio of LTM therapy is comparable with quadruple bismuth-based treatments.