Rational Helicobacter pylori Therapy: Evidence-Based Medicine Rather Than Medicine-Based Evidence

• Published in: Clinical gastroenterology and hepatology Vol. 12; no. 2; pp. 177 - 186.e3
• Main Authors: Graham, David Y, Lee, Yi–Chia, Wu, Ming–Shiang
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-02-2014
• Subjects: Amoxicillin; Amoxicillin - administration & dosage; Anti-Bacterial Agents - administration & dosage; Bismuth; Bismuth - administration & dosage; Clarithromycin; Clarithromycin - administration & dosage; Concomitant Therapy; Drug Resistance, Bacterial; Drug Therapy, Combination; Evidence Based; Evidence-Based Medicine; Gastroenterology and Hepatology; Helicobacter Infections - drug therapy; Helicobacter pylori; Humans; Metronidazole; Metronidazole - administration & dosage; Proton Pump Inhibitors; Quadruple Therapy; Review; Sequential Therapy; Tetracycline; Treatment; Treatment Failure; Treatment Success; PP; Clarithromycin; Proton Pump Inhibitors; per protocol; ITT; PPI; Review; proton pump inhibitor; Tetracycline; Treatment; intention to treat; Helicobacter pylori; modified intention to treat; Concomitant Therapy; Treatment Success; Amoxicillin; Quadruple Therapy; Bismuth; MITT; Metronidazole; Sequential Therapy; Evidence Based
• ISSN: 1542-3565; 1542-7714
• DOI: 10.1016/j.cgh.2013.05.028

Data are available such that choice of Helicobacter pylori therapy for an individual patient can be reliably predicted. Here, treatment success is defined as a cure rate of 90% or greater. Treatment outcome in a population or a patient can be calculated based on the effectiveness of a regimen for infections with susceptible and with resistant strains coupled with the knowledge of the prevalence of resistance (ie, based on formal measurement, clinical experience, or both). We provide the formula for predicting outcome and we illustrate the calculations. Because clarithromycin-containing triple therapy and 10-day sequential therapy are now only effective in special populations, they are considered obsolete; neither should continue to be used as empiric therapies (ie, 7- and 14-day triple therapies fail when clarithromycin resistance exceeds 5% and 15%, respectively, and 10-day sequential therapy fails when metronidazole resistance exceeds 20%). Therapy should be individualized based on prior history and whether the patient is in a high-risk group for resistance. The preferred choices for Western countries are 14-day concomitant therapy, 14-day bismuth quadruple therapy, and 14-day hybrid sequential-concomitant therapy. We also provide details regarding the successful use of fluoroquinolone-, rifabutin-, and furazolidone-containing therapies. Finally, we provide recommendations for the efficient development (ie, identification and optimization) of new regimens, as well as how to prevent or minimize failures. The trial-and-error approach for identifying and testing regimens frequently resulted in poor treatment success. The described approach allows outcome to be predicted and should simplify treatment and drug development.