Combination Regimens for Eradication of H. pylori (NICE Guideline)

Summary of NICE guidance on Helicobacter treatment.

NICE recommends a one-week triple therapy regimen as first-line eradication therapy. The optimum regimen, according to CKS, consists of a full dose proton pump inhibitor, with amoxicillin 1g and either clarithromycin 500mg, or (in the case of penicillin hypersensitivity) metronidazole 400mg and clarithromycin 250mg, all given twice daily. 

Efficacy

  • Eradication is effective in 80-85% of patients on triple therapy using either antibiotic combination.
  • Dual therapies are not as effective as triple therapy and are not recommended.

Resistance

  • Prescribing amoxicillin and tetracycline rarely results in H. pylori resistance, whereas resistance occurs after limited exposure to clarithromycin and quinolones.
  • Exposure to metronidazole also results in H. pylori resistance, but this has less of an impact on the effectiveness of treatment regimens.

First-line therapy

  • Choose the treatment regimen with the lowest acquisition cost and take into account previous exposure to clarithromycin or metronidazole (it is not necessary to consider previous metronidazole exposure in patients with penicillin allergy).

Second-line therapy

  • Second-line therapy should use different antibiotics to first-line therapy.
  • Seek advice from a gastroenterologist if eradication of H. pylori is not successful with second-line therapy

 First-line seven-day triple or quadruple therapy regimens

ANTIBIOTIC*

PROTON PUMP INHIBITOR

Amoxicillin 1g twice daily
and either:
Clarithromycin 500mg twice daily
or
Metronidazole 400mg twice daily**

Esomeprazole 20mg twice daily
or
Lansoprazole 30mg twice daily
or
Omeprazole 20–40mg twice daily
or
Pantoprazole 40mg twice daily
or
Rabeprazole 20mg twice daily

Penicillin allergy
Metronidazole 400mg twice daily
and
Clarithromycin 250mg twice daily

Second-line seven-day triple or quadruple therapy regimens

ANTIBIOTIC*

PROTON PUMP INHIBITOR

Amoxicillin 1g twice daily
and either:
Clarithromycin 500mg twice daily
or
Metronidazole 400mg twice daily**
(whichever was not used first-line)

Esomeprazole 20mg twice daily
or
Lansoprazole 30mg twice daily
or
Omeprazole 20–40mg twice daily
or
Pantoprazole 40mg twice daily
or
Rabeprazole 20mg twice daily

Previous clarithromycin and metronidazole exposure
Amoxicillin twice daily
and either:
A quinolone twice daily
or
Tetracycline twice daily
(whichever has the lowest acquisition cost)
Penicillin allergy + no previous quinolone exposure
Metronidazole twice daily
and
Levofloxacin twice daily

* Doses taken from NICE CKS.
** When giving amoxicillin and metronidazole with omeprazole 20mg, CKS suggests three-times daily doses of amoxicillin 500mg and metronidazole 400mg.

Adapted from: NICE Clinical Guideline 184 (September 2014) - Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management

There are additional dosages and regimens licensed for use in H. pylori eradication; refer to individual SPCs for further information.


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