Sequential Therapy for Helicobacter pylori: A Worthwhile Effort for Your Patients

Sequential therapy for Helicobacter pylori refers to the idea of adding more antibiotics to the treatment regimen but giving them in sequence rather than giving all 4 drugs together. Typically, this involves an initial 5-day therapy with a benign combination (for example, pantoprazole, 40 mg, with amoxicillin, 1 g, twice daily) followed by 5 days of 2 further antibiotics plus a proton-pump inhibitor (PPI) (for example, clarithromycin, 500 mg, and tinidazole, 500 mg, plus pantoprazole, 40 mg, twice daily), as shown below:

In a large, prospective, controlled study in 2007, Vaira and colleagues (1) showed a 90% cure rate for this “new” treatment versus 80% for the “old.” In this issue, Jafri and colleagues (2) perform a meta-analysis of clinical trials of sequential therapy. This review convincingly confirms the efficacy of sequential therapy. There are several reasons why this therapeutic strategy makes sense.

First, after a decade of clarithromycin-based treatments and continued widespread use of long-acting macrolides in general practice, 10% to 15% of H. pylori strains are resistant de novo to clarithromycin (3). As a result, the failure rate is around 20% for triple combination therapy (PPI plus amoxicillin plus clarithromycin), which was so effective when it was first evaluated 10 years ago (4, 5). Because persistent H. pylori in patients with ulcer can cause continuing ulcer complications, a failure rate of 20% also means that everyone needs follow-up proof of cure. In addition, the 20% of patients with persistent H. …