High-dose versus standard-dose PPI in triple therapy for Helicobacter pylori eradication

Empiric clarithromycin-containing triple therapies for eradication of Helicobacter pylori do not reliably produce a >= 80% success rate on an intention-to-treat basis. This lack of adequate treatment response is primarily because of clarithromycin resistance. This commentary discusses the findings of a meta-analysis by Villoria et al. that investigated whether a triple therapy containing a high-dose PPI and clarithromycin plus either amoxicillin or tinidazole improves the success rate of H. pylori eradication compared with a triple therapy that contains a standard-dose PPI. The mean intention-to-treat cure rates were greater in patients who used the high-dose PPI regimen compared with the standard-dose regimen (82% vs 74%, respectively). However, the actual cure rates of these studies were poor and the improvements were unlikely to be clinically significant. The prevalence of clarithromycin resistance in most of the world is such that clarithromycin-containing triple therapy should not be used empirically. Alternatives include sequential or concomitant therapy and bismuth-containing quadruple therapies.