Further poly- to the pills for Helicobacter pylori eradication?

▶ Malfertheiner P, Bazzoli F, Delchier JC, et al. H pylori eradication with a capsule containing bismuth subcitrate potassium, metronidazole, and tetracycline given with omeprazole versus clarithromycin-based triple therapy: a randomised, open-label, non-inferiority, phase 3 trial. Lancet 2011;377:905–13.

H pylori is the main cause of peptic ulcer and gastric cancer worldwide. Eradication of the bacterium is therefore advocated in most patients found to be infected with it. Proton pump inhibitor-based triple therapy is the accepted first-line therapy, but their have been concerns about reduced efficacy in recent years. Bismuth-based quadruple therapy is reserved as second-line therapy, due to concerns regarding tolerability.

This randomised controlled trial conducted in Europe by Malfertheiner and colleagues recruited 440 H pylori-positive patients with upper gastrointestinal symptoms and randomised them to receive Proton pump inhibitor triple therapy or bismuth quadruple therapy. The primary outcome was successful H pylori eradication, which required two negative carbon-urea breath tests at 6 and 10 weeks post-treatment.

The authors demonstrated a significantly superior eradication rate with quadruple therapy compared with triple therapy in their intention to treat analysis, 80% versus 55%. Adverse events were no commoner with quadruple therapy. They concluded that quadruple therapy should be considered as a first-line therapy for the treatment of H pylori. …