Credits Earned (2024) Crédits obtenus

Redeem Prepaid Membership

Tools for Practice Outils pour la pratique

#56 Is Quadruple the New Triple Therapy for H. Pylori?

Does quadruple therapy (QT) result in superior eradication rates of H. pylori over traditional triple therapy (TT)?

Optimal treatment regimens for H. pylori remain controversial, with differences in number and type of drugs, dosing, and length of treatment suggested. Until local resistance patterns are identified and deemed a concern, there is no overwhelming evidence to change current prescribing patterns in primary care.

CFPCLearn Logo

Reading Tools for Practice Article can earn you MainPro+ Credits

La lecture d'articles d'outils de pratique peut vous permettre de gagner des crédits MainPro+

Join Now S’inscrire maintenant

Already a CFPCLearn Member? Log in

Déjà abonné à CMFCApprendre? Ouvrir une session

Aindustry funded trial1 of 440 European patients reported significant benefit with QT for 10 days compared to TT for seven days (93% versus 68% eradication, Number Needed to Treat (NNT)=5). 
  • QT was omeprazole BID with bismuth subcitrate, metronidazole, and tetracycline QID. 
  • TT was omeprazole, amoxicillin, and clarithromycin BID. 
  • Concerns: Differing treatment durations, differing antibiotics, bismuth subcitrate not commercially available in Canada, questionable generalizability.  
Recent systematic reviews2,3 found no difference in eradication rates, or adverse events between QT and TT: 
  • For example, eradication rate 78% QT and 77% TT.2  
  • Compliance minimally better with TT in one review (96% versus 92%)3, with no difference in the other.2 
  • Eradication rates for H. pylori may be suboptimal (<80%) worldwide4-6 due to increasing antibiotic resistance, but are >80% in Canada.7 
    • Resistance varies by geographical region and local resistance patterns (which are often not known).8 
  • Clarithromycin resistance should guide initial H. pylori treatment choices.  
    • Avoid if resistance rates ≥ 20%.9 
  • Canadian recommendations include both triple or quadruple therapy as first line therapies for H. pylori eradication, but prefer TT due to demonstrated equivalency and ease of dosing.10 
  • Cost effectiveness data comparing QT and TT and length of therapy is lacking.  
  • Emerging H. pylori eradication therapies that may have superior eradication rates compared with QT or TT (but whose results iNorth American patients are lackinginclude:11-14 
    • Sequential therapy (10 -14 days): Amoxil plus PPI for 5-7 days, then Metronidazole, Clarithromycin, and PPI for 5-7 days. 
    • Concomitant therapy (TT plus metronidazole) for 7-14 days. 
updated may 21 2015 by adrienne

Latest Tools for Practice
Derniers outils pour la pratique

#370 Antibiotics or no antibiotics for acute diverticulitis, that is the question!

Do antibiotics change clinical outcomes for patients with acute uncomplicated diverticulitis?
Read Lire 0.25 credits available Crédits disponibles

#369 Remind me, do medications that target brain amyloid improve my dementia?

Are amyloid-targeting monoclonal antibodies safe and effective for mild cognitive impairment or Alzheimer’s dementia?
Read Lire 0.25 credits available Crédits disponibles

#368 Sodium Restriction in Heart Failure: Beneficial or pouring salt in the wound?

Does sodium restriction improve outcomes in patients with chronic heart failure?
Read Lire 0.25 credits available Crédits disponibles

This content is certified for MainPro+ Credits, log in to access

Ce contenu est certifié pour les crédits MainPro+, Ouvrir une session

  • Christina Korownyk MD CCFP
  • Michael R Kolber BSc MD CCFP MSc

1. Malfertheiner P, Bazzoli F, Delchier JC, et al. Lancet. 2011; 377(9769):905-13.

2. Luther J, Higgins PD, Schoenfeld PS, et al. Am J Gastroenterol. 2010; 105(1):65-73.

3. Venerito M, Krieger T, Ecker T, et al. Digestion. 2013; 88:33-45.

4. European Helicobacter Pylori Study Group [No authors listed]. Gut. 1997; 41(1):8-13.

5. Graham DY, Fischbach L. Gut. 2010; 59(8):1143-53.

6. Graham DY, Lu H, Yamaoka Y. Helicobacter. 2007; 12(4):275-8.

7. Rodgers C, van Zanten SV. Can J Gastroenterol. 2007; 21(5):295-300.

8. Fallone CA. Can J Gastroenterol. 2000; 14(10):879-82.

9. Malfertheiner P, Megraud F, O'Morain C, et al. Gut. 2012; 61:646-64.

10. Hunt R, Fallone C, Veldhuyzan van Zanten S, et al. Can J Gastroenterol. 2004; 18(9):547-54.

11. Graham DY, Fischbach LA. CMAJ. 2011; 183(9):E506-8.

12. Gatta L, Vakil N, Vaira D, et al. BMJ. 2013; 347:f4587.

13. Vaira D, Zullo A, Vakil N, et al. Ann Intern Med. 2007; 146(8):556-63.

14. Molina-Infante J, Lucendo AJ, Angueira
T, et al. Aliment Pharmacol Ther. 2015; 41:581-9.

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.

Most recent review: 21/05/2015

By: Adrienne J Lindblad BPS ACPR Pharm


Evidence Updated: Systematic review added; Bottom Line: Unchanged.

Learning at a glance
Yearly credits
Acquired ()
Your content by topic
Cardiology Dermatology Emergency
My Bookmarks