A seven-day course of triple therapy should no longer be first-line treatment for eradicating Helicobacter pylori according to an Australian expert.

Professor Nicholas Talley, a gastroenterologist and professor of medicine at Newcastle University, says a comprehensive meta-analysis published recently in the BMJ has confirmed long-standing suspicions that widespread clarithromycin resistance is undermining the effectiveness of the standard treatment, leaving current guidelines out of date.

He says most specialists and GPs rely on seven days of concomitant treatment (proton pump inhibitor and clarithromycin, together with amoxicillin or metronidazole) as first-line therapy, but the BMJ study showed this to be least effective treatment of 14 well-established or newer treatment regimes.

According to Professor Talley this poses a dilemma for prescribers, given that triple therapy is the only regime commercially available in Australia.

One solution would be to opt for 14 days of triple therapy, but this has been shown to increase the rate of side effects.

“Two weeks of bismuth with a PPI and two antibiotics is a good approach. That should probably, in my view, be standard treatment now for many cases” Professor Talley told the limbic.

However access to bismuth was currently restricted because it was only available under the TGA special access scheme, he said.

“There is now enough evidence to revisit guidelines and there also needs to be some effort put into the TGA making bismuth available for appropriate indications and quadruple therapy.

“Two weeks of bismuth with a PPI and two antibiotics is a good approach. That should probably, in my view, be standard treatment now for many cases, but you need to have bismuth to be able to do that.”

“There is now enough evidence to revisit guidelines and there also needs to be some effort put into the TGA making bismuth available for appropriate indications and quadruple therapy.

Professor Talley says another shift in thinking is also required in terms of checking, after treatment, whether the infection has been eradicated.

“The current guidelines don’t require you to check eradication rates, but that is also out of date as it assumes high success rates,” he says.

The good news, Professor Talley says, is that despite diminishing rates of treatment success, the prevalence of H. pylori in Australia has fallen over the past few decades due to improved hygiene.

“Even though the success rate of treatment is falling, there isn’t a very high rate of peptic ulcer. That’s the good news. But if you have the infection and you get an ulcer, then the bad news is that our treatments aren’t particularly successful,” he says.