Patient Care

Standard Triple Therapy for H. Pylori Lowest Ranked among 14 Treatment Regimens


Clinical question: How do current Helicobacter pylori treatments compare in efficacy and tolerance?

Background: Efficacy of standard “triple therapy” for H. pylori (proton pump inhibitor plus clarithromycin and amoxicillin or metronidazole) is declining due to the development of antibiotic resistance. Different medication combinations and/or time courses are currently used, but comparative effectiveness of these treatments has not been evaluated comprehensively.

Study design: Systematic review and network meta-analysis.

Setting: Cochrane Library, PubMed, and Embase databases.

Synopsis: One hundred forty-three RCTs evaluating a total of 14 treatments for H. pylori were identified. Network meta-analysis was performed to rank order treatments for efficacy (eradication rate of H. pylori) and tolerance (adverse event occurrence rate). Seven days of “concomitant treatment” (proton pump inhibitor plus three antibiotics) ranked the highest in efficacy (eradication rate 0.94; 95% confidence interval [CI] 0.89-0.98), though this treatment group comprised a very small proportion of overall participants and studies and may be subject to bias. Seven days of standard “triple therapy” ranked the lowest in efficacy (eradication rate 0.73; 95% CI 0.71-0.75).

Of note, subgroup analysis showed variation in efficacy rankings by geographic location, suggesting that findings may not be universally applicable. Only two treatments showed significantly different adverse event occurrence rates compared to standard “triple therapy,” indicating overall similar tolerance for most treatments.

Bottom line: Several treatment regimens may be more effective than standard H. pylori “triple therapy” and equally well tolerated.

Citation: Li BZ, Threapleton DE, Wang JY, et al. Comparative effectiveness and tolerance of treatments for Helicobacter pylori: systematic review and network meta-analysis. BMJ. 2015;351:h4052.

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