H pylori eradication therapy (NICE)

Helicobacter pylori: triple therapy (1,2):

Eradication

First-line treatment

offer people who test positive for H pylori a 7-day, twice-daily course of treatment with:
- a PPI (see table in notes) and
- amoxicillin 1g and
- either clarithromycin 500mg or metronidazole 400mg
offer people who are allergic to penicillin a 7-day, twice-daily course of treatment with:
- a PPI (see table in notes) and
- clarithromycin 250mg and
- metronidazole 400mg
offer people who are allergic to penicillin and who have had previous exposure to clarithromycin a 7-day, twice-daily course of treatment with:
- a PPI (see table in notes) and
- bismuth and
- metronidazole 400mg and
- tetracycline 500mg

Second-line treatment

offer people who still have symptoms after first-line eradication treatment a 7-day, twice-daily course of treatment with:
- a PPI (see table in notes) and
- amoxicillin 1g bd and
- either clarithromycin 500mg bd or metronidazole 400mg bd (whichever was not used first-line)
offer people who have had previous exposure to clarithromycin and metronidazole a 7-day, twice-daily course of treatment with:
- a PPI (see table) and
- amoxicillin 1g and
- a quinolone or tetracycline 500mg
offer people who are allergic to penicillin (and who have not had previous exposure to a quinolone) a 7-day, twice-daily course of treatment with:
- a PPI (see table) and
- metronidazole 400mg and
- levofloxacin 250mg
offer people who are allergic to penicillin and who have had previous exposure to a quinolone:
- a PPI (see table) and
- bismuth and
- metronidazole 400mg and
- tetracycline 500mg

Seek advice from a gastroenterologist if eradication of H pylori is not successful with second-line treatment

Notes (2):

there is evidence that the addition of bovine lactoferrin to triple therapy led to an increase in Helicobacter pylori eradication (3)
- a more recent meta-analysis concluded that "...supplementation with probiotics could be effective in increasing eradication rates of anti-H. pylori therapy, and could be considered helpful for patients with eradication failure. Furthermore, probiotics show a positive impact on H. pylori therapy-related side effects.." (4)
quadruple therapy for H. pylori
- a meta-analysis revealed that quadruple therapy appeared to be more effective than triple therapies for eradicating single-drug resistant H. pylori infection (5)
  - the study authors observed that resistance to metronidazole or clarithromycin could be overcome to a great extent with quadruple therapies given for 5 or more days, especially those containing metronidazole and clarithromycin concomitantly

PPI doses for H pylori eradication therapy (1)

use of quinaolones - See MHRA advice for restrictions and precautions for using fluoroquinolone antibiotics due to very rare reports of disabling and potentially long-lasting or irreversible side effects affecting musculoskeletal and nervous systems. Warnings include: stopping treatment at first signs of a serious adverse reaction (such as tendonitis), prescribing with special caution in people over 60 years and avoiding coadministration with a corticosteroid (March 2019).

Reference:

Last edited 11/2019

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