H. PYLORI ERADICATION OPTIONS FOR PEPTIC ULCER DISEASE Acid Suppressant Antibiotic 1 Antibiotic 2 Treatment Duration Proton Pump Inhibitor-Based Treatments Aciphex Triple therapy rabeprazole 20mg amoxicillin 1000mg clarithromycin 500mg twice 7 days with AM and PM meals twice daily twice daily daily Nexium Triple therapy esomeprazole amoxicillin 1000mg clarithromycin 500mg twice 10 days 40mg once daily twice daily daily Prevacid Triple therapy lansoprazole 30mg amoxicillin 1000mg clarithromycin 500mg twice 10 or 14 days twice daily twice daily daily Sold in combination pack as Prevpac Dual therapy lansoprazole 30mg amoxicillin 1000mg — 14 days three times daily three times daily Prilosec Triple therapy omeprazole 20mg amoxicillin 1000mg clarithromycin 500mg twice 10 days twice daily twice daily daily If ulcer present, may continue omeprazole 20mg once daily add’l 18 days Dual therapy omeprazole 40mg clarithromycin 500mg — 14 days once daily three times daily If ulcer present, may continue omeprazole 20mg once daily add’l 14 days Other Combination Therapy Helidac Quadruple therapy choose an H2 metronidazole tetracycline 500mg with Sold as combination pack. Take receptor antagonist 250mg four times 2 bismuth subsalicylate with full glass of water. Treat for daily 262.4mg chew tabs four 14 days. times daily Pylera Quadruple therapy omeprazole 20mg Metronidazole 125mg, tetracycline 125mg, Omeprazole sold separately. Take twice daily bismuth subcitrate 140mg in 1 cap. Take 3 caps with full glass of water. Treat for 4 times daily. 10 days. H2 Receptor Antagonist-Based Treatments nizatidine Triple therapy nizatidine 300mg any of the above combinations Take with 2 antibiotics for 2wks. at bedtime May take nizatidine for total of 4–8wks. Pepcid Triple therapy famotidine 40mg any of the above combinations Take with 2 antibiotics for 2wks. daily at bedtime May take Pepcid for total of 4–8wks. Tagamet Triple therapy cimetidine 800mg any of the above combinations Take with 2 antibiotics for 2wks. at bedtime May take Tagamet for total of 4–8wks. Zantac Triple therapy ranitidine 300mg any of the above combinations Take with 2 antibiotics for 2wks. daily in PM or May take Zantac for total of bedtime 4–8wks. NOTES • Shorter courses of treatment have demonstrated eradication rates of 82295% with potential for increased compliance, fewer adverse effects, and reduced costs • Regimens should be kept simple (eg, twice-daily) to optimize compliance • Empirical H. pylori eradication for non-ulcer dyspepsia is not indicated • Bismuth subsalicylate (eg, Pepto Bismol) is no longer widely used; may be added in refractory cases • Two antibiotic combinations are more effective and less likely to cause the emergence of resistant strains • Clinical judgment is valid for off-label changes (eg, substituting doxycycline for tetracycline). Off-label uses of drugs with a high probability of success include, but are not limited to, amoxicillin/clavulanate (Augmentin) 500mg twice daily, clindamycin (Cleocin) 600mg twice daily, doxycycline 100mg twice daily. Erythromycin 500mg twice daily is a potential substitute for clarithromycin. Regimens and doses on this chart are not necessarily those suggested in product labeling. • Return visit required to document improvement. Lack of improvement suggests a different diagnosis. REFERENCES This chart was prepared by Wm. MacMillan Rodney, M.D., FAAFP. Ables AZ, Simon I, Melton ER. Update on Helicobacter Pylori Treatment. Am Fam Physician 2007;72:351-8. (Rev. 6/2013)