Quadruple therapy versus standard triple therapy for eradication of Helicobacter pylori in Kuwait

Comparison of the efficacies of triple, quadruple and sequential antibiotic therapy in eradicating Helicobacter pylori infection: A randomized controlled trial

BACKGROUND AND AIM

There is regional variation in the eradication rates of Helicobacter pylori (H. pylori) regimens depending on the local antibiotic resistance patterns. The aim of this study was to compare the efficacies of triple, quadruple and sequential antibiotic therapy in eradicating H. pylori infection.

METHODS

A total of 296 H. pylori-positive patients were randomized to receive one of the three regimens (triple, quadruple or sequential antibiotic therapy) and eradication rate was assessed by H. pylori stool antigen test.

RESULTS

The eradication rates of standard triple therapy, sequential therapy and quadruple therapy were 93%, 92.9% and 96.4%, respectively (p = 0.57).

CONCLUSION

Fourteen days of standard triple therapy, 14 days of bismuth-based quadruple therapy and 10 days of sequential therapy are equally efficacious in eradicating H. pylori and all regimens have optimum H. pylori eradication rates.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: CTRI/2020/04/024929.

Brief communication: global temporal trends in the efficacy of clarithromycin-based regimens for the treatment of Helicobacter pylori infection

Background

Helicobacter pylori eradication rates achieved with clarithromycin-based triple therapies are declining due to antibiotic resistance, but data regarding temporal changes in efficacy with these eradication therapies are scarce.

Objective

To evaluate the efficacy of clarithromycin-based triple eradication regimens over time.

Design

A comprehensive literature review and time-trend analysis.

Data sources and methods

Bibliographies of recently published systematic literature reviews were searched and supplemented with a targeted literature review conducted using Medline and Embase databases and ProQuest from conception to May 2021. Studies reporting H. pylori eradication rates of clarithromycin-based triple therapies were included and temporal trends were estimated using a random-effects model.

Results

Eradication rates for triple therapies containing proton pump inhibitors (PPIs), clarithromycin, and amoxicillin showed a significant decline over the past 23 years (p = 0.0315). However, this decline was not significant when eradication rates achieved with vonoprazan-based triple therapy were included (p = 0.3910).

Conclusion

Vonoprazan-based triple therapy partially mitigated the decline in eradication rates seen with PPI-based triple therapy, likely due to more powerful acid suppression of vonoprazan.

Comparison of the improvement in gastric mucosal tissue after Helicobacter pylori eradication between young and elderly people

BACKGROUND AND STUDY AIMS

Helicobacter pylori (H. pylori) infection has been clearly shown to be a cause of gastric cancer, and the incidence of gastric cancer has been shown to decrease with eradication. However, few reports have described the utility of eradication therapy in elderly people. Thus, an investigation focusing on how much actual histological improvement is obtained with eradication therapy in elderly people was conducted.

PATIENTS AND METHODS

This was a retrospective study conducted using medical information of patients diagnosed with H. pylori-associated gastritis and who underwent eradication therapy. The histological improvement was assessed based on changes in the atrophy and intestinal metaplasia scores of the Updated Sydney system from before to after eradication. We investigated the rates of histological improvement in atrophy and intestinal metaplasia one year after and long term more than five years after H. pylori eradication in an elderly group and a younger group.

RESULTS

This study included 221 patients (elderly group 123, younger group 98). In histological atrophy, higher rates of improvement were seen in the corpus than in the antrum, and the rates of cure in the antrum were lower in elderly group than in younger group (p = 0.0282). With regard to intestinal metaplasia, the rates of improvement in the antrum were lower in elderly group than in younger. In long term observation, although the rates of cure in the antrum were lower in elderly, improvements were seen in atrophy scores in most of the patients and intestinal metaplasia scores in about half of patients.

CONCLUSION

Though there is more obvious improvement in the gastric mucosa when H. pylori eradication therapy is performed at a young age, some mucosal improvement can be expected in about half of patients after eradication, even in elderly people.

Cost-Effectiveness Analysis of Hp and New Gastric Cancer Screening Scoring System for Screening and Prevention of Gastric Cancer

Gastric cancer is one of the most common gastrointestinal cancers. Early diagnosis can improve the 5-year survival rate. This study aimed to evaluate the cost-effectiveness of Helicobacter pylori (Hp) and a new gastric cancer screening scoring system (NGCS) in areas with a high incidence of gastric cancer. A decision-analytic Markov model was constructed based on the theory and method of cost-effectiveness analysis, which included three decisions: no screening, Hp screening, and NGCS screening. The uncertainty of each parameter in the model was determined using a one-way sensitivity analysis and probability sensitivity analysis. The results of the cost-effectiveness analysis revealed that the application of the NGCS had the highest cost-effectiveness, while the one-way sensitivity analysis revealed that the probability of intestinal metaplasia progression to dysplasia had the most significant effect on the incremental cost-effectiveness ratio. The probability sensitivity analysis concluded that the result of the NGCS having the highest cost-effectiveness was stable. Although the application of the NGCS will require upfront screening costs, it can significantly improve the detection rate of early gastric cancer and save the consequent long-term healthcare costs. It is practicable and can be popularized in China.

2022 Chinese national clinical practice guideline on Helicobacter pylori eradication treatment

BACKGROUND

Helicobacter pylori ( H. pylori ) infection is an infectious disease with a prevalence rate of up to 50% worldwide. It can cause indigestion, gastritis, peptic ulcer, and gastric cancer. H. pylori eradication treatment can effectively control disease progression and reduce the risk of the above conditions. However, the escalating trend of antibiotic resistance presents a global challenge for H. pylori eradication. We aim to provide guidance on pharmacological treatment of H. pylori infection.

METHODS

This clinical practice guideline is developed following the World Health Organization's recommended process, adopting Grading of Recommendations Assessment, Development and Evaluation in assessing evidence quality, and utilizing Evidence to Decision framework to formulate clinical recommendations, minimizing bias and increasing transparency of the clinical practice guideline development process. We used the Reporting Items for practice Guidelines in HealThcare (RIGHT) statement and The Appraisal of Guidelines for Research and Evaluation II (AGREE II) as reporting and conduct guides to ensure the guideline's completeness and transparency.

RESULTS

Though decreasing in developed countries, the prevalence of H. pylori remains high in developing countries, causing a major public health burden. This clinical practice guideline contains 12 recommendations concerning pharmacological treatment for H. pylori eradication. Among them, it is worth highlighting that bismuth preparations are inexpensive, safe, and effective, consequently making bismuth quadruple therapy a preferred choice for initial and rescue treatment. In empirical treatment, high-dose dual therapy is equally effective compared with bismuth quadruple therapy.

CONCLUSIONS

The 12 recommendations in this clinical practice guideline are formed with consideration for stakeholders' values and preferences, resource use, feasibility, and acceptability. Recommendations are generalizable to resource limited settings with similar antibiotic resistance pattern as China, and lower middle-income countries facing comparable sociological and technical challenges.

REGISTRATION

Guidelines International Network (GIN) website, https://guidelines.ebmportal.com/node/69996 .

Potassium-Competitive Acid Blocker and Proton Pump Inhibitor-Based Regimens for First-Line Helicobacter pylori Eradication: A Network Meta-Analysis

Background and Aims

Effective acid suppression is a crucial component of Helicobacter pylori (H. pylori) eradication regimens. Approved treatments include dual, triple, and quadruple therapies composed of certain antibiotics in combination with proton pump inhibitors (PPIs). Vonoprazan, a potassium-competitive acid blocker, provides more potent and durable acid suppression than PPIs. We compared the efficacy of vonoprazan-based therapies vs approved standard regimens using new evidence from the phase 3 pHalconHP trial in North America and Europe.

Methods

Studies reporting first-line H. pylori eradication rates from empiric treatment with Food and Drug Administration-approved therapies and vonoprazan-containing therapies were identified via bibliographic searches of systematic literature reviews and a subsequent MEDLINE/Embase search using index terms for H. pylori and eradication. Randomized controlled trials comparing 2 or more relevant comparators were included in Bayesian network meta-analyses for grouped and distinct therapies.

Results

Twenty-three distinct regimens from 42 trials including 12,773 patients were identified. Vonoprazan-based triple therapy showed the highest relative efficacy (odds ratio: 2.73, 95% credible interval 2.11, 3.54) and 72.1% probability of being the best. North American, Western, and global scenarios were largely consistent. Vonoprazan-based therapies demonstrated higher odds of H. pylori eradication than each PPI-based triple therapy. Furthermore, vonoprazan-based triple therapy was superior to bismuth subcitrate quadruple therapy (odds ratio: 1.60, 95% credible interval: 1.07, 2.38).

Conclusion

Vonoprazan-based eradication regimens represent novel treatments for H. pylori infection on a global scale, offering efficacy that, in this analysis, is superior to PPI-based triple therapy and comparable or better than bismuth quadruple therapy.

A randomized clinical trial comparing triple therapy versus non-bismuth based quadruple therapy for the eradication of Helicobacter Pylori in Kuwait

Introduction:

Helicobacter pylori-induced chronic infection is associated with peptic ulcer, chronic gastritis, gastric cancer, and increasing antibiotic resistance. We aimed to evaluate the efficacy of clarithromycin-based triple therapy and non-bismuth based quadruple therapy for eradicating H. pylori in patients with chronic gastritis in Kuwait.

Methods:

We enrolled a total of 603 treatment-naive dyspeptic patients with gastric biopsy-proven chronic gastritis secondary to H. pylori in a prospective, open-label, randomized study. Patients were randomized into two groups: a group received the standard triple therapy (omeprazole, amoxicillin, and clarithromycin) for 14 days and a group received quadruple therapy (omeprazole, amoxicillin, clarithromycin, and metronidazole) for 14 days. All patients were tested for the eradication of H. pylori by carbon-13 urea breath test 1 month after eradication therapy.

Results:

The overall eradication rate was 63.2%. The eradication rates in intention-to-treat (ITT) and per protocol (PP) population were 58.4% and 64.6%, respectively, in triple therapy group. In the quadruple therapy group, the eradication rates in ITT and PP population were 68.0% and 78.5%, respectively, with a statistically significant higher eradication rate in patients treated by quadruple therapy than the triple therapy (P < 0.01). Multivariate logistic regression analysis revealed that treatment regimen was the only significant predictor for successful H. pylori eradication. The most common adverse events were abnormal taste, headache, dizziness, and abdominal pain.

Conclusion:

Non-bismuth based quadruple therapy is more effective than standard clarithromycin-based triple therapy for eradicating H. pylori in patients with chronic gastritis.

ClinicalTrials.gov Identifier: NCT04617613

Cost-Effectiveness Analysis of Helicobacter pylori Eradication Therapy for Prevention of Gastric Cancer: A Markov Model

BACKGROUND

Helicobacter pylori (H. pylori) eradication can reduce the prevalence of gastric cancer. However, whether H. pylori eradication therapy should be performed in infected patients, especially in asymptomatic cases, is still controversial.

AIMS

The aims of this study were to determine whether H. pylori screening and eradication could prevent gastric cancer in a cost-effective way, and further whether eradication therapy should be administered to asymptomatic individuals.

METHODS

Cost-effectiveness analysis was performed using a Markov model. We established two groups, each with 10,000 hypothetical Chinese individuals at the age of 40 years. Clinical outcomes and cost of H. pylori eradication were compared between the eradication and control groups.

RESULTS

There was a lower morbidity with gastric cancer in the eradication group than in the control group, which was most significant after running the model for 15 years. The eradication group experienced an average of 34.64 quality-adjusted life years (QALYs) per person, and the average cost was US $1706.52 per person. The control group exhibited an average of 32.63 QALYs per person, and the average cost was US $2045.10 per person. The cost-effectiveness analysis showed that eradication saved $1539 per LY per person and $168.45 per QALY per person.

CONCLUSIONS

H. pylori screening and eradication therapy effectively reduces the morbidity of gastric cancer and cancer-related costs in asymptomatic infected individuals. Therefore, we believe that H. pylori eradication can prevent gastric cancer in a cost-effective way.

Comparison between different first-line therapy protocols in eradicating Helicobacter pylori in a region with high clarithromycin resistance

Introduction

Helicobacter pylori infection is encountered in more than 50% of the world population. A high rate of clarithromycin resistance is observed among Helicobacter pylori strains in some regions because clarithromycin is a drug commonly used for the treatment of other infections.

Aim

To identify an efficient eradication protocol for patients infected with H. pylori and to suggest an alternative first-line therapy particularly in countries with high clarithromycin resistance.

Material and methods

Patients (18-75 years old) having dyspeptic complaints in a 1-year period and diagnosed with H. pylori infection by gastric biopsy were included and randomised to three groups, each receiving different sequential eradication therapy (LAM-B: lansoprazole, amoxicillin, metronidazole, bismuth: LAM-T: lansoprazole, amoxicillin, metronidazole, tetracycline; LAM-BT: lansoprazole, amoxicillin, metronidazole, bismuth, tetracycline). Eradication was evaluated via urea breath test.

Results

This study included 166 patients (mean age: 40 ±12 years; female, 68.7%) with H. pylori infection. Among them, 50 (30.1%) were in the LAM-B group, 59 (35.5%) were in the LAM-T group, and 57 (34.3%) were in the LAM-BT group. The non-steroidal anti-inflammatory drug use was the lowest in the LAM-BT group. Eradication rates were over 80% and similar in each group, with the highest rate in the LAM-BT group (93%). Adverse event rate was the highest in the LAM-T group. Helicobacter pylori eradication was achieved in 143 (86.1%) patients.

Conclusions

The combination regimens without clarithromycin achieved an eradication rate over 80% in all groups. Knowing and monitoring the regional antibiotic resistance rates is important for successful treatment of H. pylori infections.

Current status of Helicobacter pylori infection and evolution of treatment strategy in China

Infection with Helicobacter pylori (H. pylori) has become a common digestive disease and the prevalence of H. pylori infection remains high in the Chinese population. Recently, the Kyoto global consensus report on H. pylori gastritis and the Toronto consensus for the treatment of H. pylori infection in adults were issued. Therefore, it is essential to discuss the prevention and control of H. pylori infection in China. Due to severe resistance to antibiotics, toxic and host factors, the eradication rate in China has currently became lower than before. Therefore, whether to intervene H. pylori infection in the asymptomatic population and enlarge the indication for eradication and the cost-effect for this new strategy should be discussed. In addition, the implementation of the "test and treat" policy or not in China is debatable. Developing optimal treatment strategy has become a major challenge that clinicians face. This review focuses on the current H. pylori infection situation and the evolution of treatment strategies in China.

Update on prevention and treatment of Helicobacter pylori infection

From the first isolation of Helicobacter pylori (H. pylori) from the gastric mucosa by Marshall and Warren in 1983, 33 years have passed. H. pylori has been found to be closely associated not only with chronic gastric diseases but also with multiple system diseases. Advances in research of H. pylori infection has led to a better understanding of the pathogenicity of H. pylori and the prevention and treatment of related disease. In 2015, Professor Zou's team developed oral recombinant H. pylori vaccine, which is promising in the prevention of H. pylori infection. Japan aims to reduce the risk of H. pylori infection in the whole population in 2014 to reduce the incidence of gastric cancer, which has caused widespread concern. H. pylori infection is a kind of infectious disease, and the infection rate in China is about 56%.Therefore, it is of great clinical importance to strengthen the research on bacteriology and pathogenesis of H. pylori, improve the prevention and treatment related diseases, and seek antibacterial regimens with better efficacy and lower drug resistance.