Updated H. Pylori Regimens – Quadruple Therapy

Due to increasing resistance (~15% in some locales) of H pylori to clarithromycin, triple therapy (PPI + 2 abx) is no longer recommended.  QUADRUPLE therapy (options below) are now recommended.

From Prescriber’s Letter:

Select an initial regimen based on prior macrolide exposure, allergies, dosing convenience, and cost. All PPIs are equally effective.

Regimen

Combinations

Comments

Cost/Course

Concomitant
quadruple therapy

PPI BID
+ Clarithromycin 500 mg BID
+ Amoxicillin 1,000 mg BID
+ Metronidazole 500 mg BID

First-line
More convenient dosing

~$50 up to $985
for Prevpac + metronidazole

Bismuth quadruple therapy

PPI BID
+ Bismuth subsalicylate 262 mg QID
+ Tetracycline 500 mg QID
+ Metronidazole 250 mg QID

First-line
Good for prior macrolide exposure or
true penicillin allergy

~$200 to $750

Triple
therapy

PPI BID
+ Clarithromycin 500 mg BID
+ Amoxicillin 1,000 mg BID
OR Metronidazole 500 mg TID

No longer preferred
Consider if no prior macrolide exposure and clarithromycin resistance < 15%

~$35 up to $970 for Prevpac

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