Explore Different Med Regimens for H. pylori

In this episode, TRC Healthcare editor, Rachel Cole, PharmD, unpacks the updated recommendations for H. pylori management, spotlighting why bismuth quadruple therapy is now front and center and how to navigate antibiotic resistance and patient-specific factors. You’ll come away with actionable pearls on regimen selection, adherence strategies, and which drug interactions to watch for. 

This is an excerpt from our February 2025 Pharmacy Essential Updates continuing education webinar series.

The clinical resources mentioned during the podcast are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights: 

• Article: Stay Current on H. pylori Treatment Guidance
• Chart: Helicobacter pylori: From Diagnosis to Eradication
• Graphic: Helicobacter pylori Treatment Summary

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Transcript

This transcript is automatically generated. 

00:00:04 Narrator

Welcome to Clinical Capsules from TRC Healthcare, your go-to podcast for fast, evidence-based insights. 

00:00:10 Narrator

On this episode, Assistant Editor and Clinical Pharmacist Rachel Cole unpacks the updated recommendations for H. pylori management in an excerpt from our popular Pharmacy Essential Updates webinar series.  

00:00:23 Narrator

TRC has been a trusted resource for healthcare professionals for over 40 years—and now we’re bringing that expertise straight to your ears every 2nd and 4th Tuesday, in bite-sized, actionable episodes…right here on Clinical Capsules.

00:00:36 Narrator

With that, Let's get started…

00:00:44 Rachel Cole

So, let's begin by discussing some of the updated guidance for the treatment of H pylori and infection in the stomach that can cause ulcers.

00:00:53 Rachel Cole

And like our article says, you'll see a shift in the treatment of H pylori infections based on recent guidelines from the American College of Gastroenterology.

00:01:04 Rachel Cole

So, what is H pylori?

00:01:06 Rachel Cole

Helicobacter pylori is a gram negative spiral shaped bacterium that colonizes the gastric mucosa, or the stomach lining and has adapted to survive in this very acidic environment. It's found in somewhere between 30 to 40% of the US population and is a known cause of gastric and duodenal ulcers.

00:01:26 Rachel Cole

And a risk factor for gastric cancer.

00:01:30 Rachel Cole

When it comes to H pylori treatment, we're probably most familiar with the clarithromycin based triple therapy, which includes clarithromycin, a proton pump inhibitor or PPI like omeprazole and amoxicillin or metronidazole. And even though rising resistance to this regimen has been reported for years, it continues to be the most prescribed regimen.

00:01:52 Rachel Cole

For H pylori in the US.

00:01:54 Rachel Cole

And because resistance continues to be a concern for these antibiotics, the meds that are recommended to treat H pylori are shifting to help increase eradication rates or get rid of the infection more effectively.

00:02:07 Rachel Cole

For example, in some areas, antibiotics such as clarithromycin, metronidazole and levofloxacin can see resistance rates of about 30 to 40%.

00:02:18 Rachel Cole

In fact, H pylori regimens containing clarithromycin or levofloxacin are now only preferred if susceptibility is proven or there's a high local eradication rate. So new guidance is shifting focus to optimize quadruple therapy, and all treatment regimens are now recommended for 14 days.

00:02:40 Rachel Cole

Instead of seven to 10.

00:02:43 Rachel Cole

Another regimen we may be familiar with is concomitant quadruple therapy, but because it also contains clarithromycin, it's now only recommended if susceptibility to clarithromycin is known or suspected. This is also not a good choice for patients who've taken clarithromycin or any other macrolide, so optimize bismuth.

00:03:03 Rachel Cole

Quadruple therapy or BQT is preferred for those with prior macrolide exposure, or who have a true penicillin allergy.

00:03:03 Rachel Cole

In treatment naive patients optimized bismuth quadruple therapy is recommended in patients treated without knowing prior antibiotic exposure or who have a true penicillin allergy.

00:03:24 Rachel Cole

Regimens that include the antibiotic rifabutin now have a role as first line options in some cases like rifabutin triple therapy available in a combo pack called Talicia, or the newer gastric acid suppressing med vonoprazan or Voquezna. So let's dig into each of them separately to get a better understanding of these.

00:03:48 Rachel Cole

So, let's start with what exactly is optimized BQT and how is it different from regular BQT? Optimized means we're either increasing A dose and/or the frequency of some of these components and a duration of 14 days instead of 10.

00:04:07 Rachel Cole

Optimized BQT includes bismuth dosed at 300 milligrams four times daily, at least metronidazole 1.5 to 2 grams daily in 3 or 4 divided doses.

00:04:20 Rachel Cole

Tetracycline, 500 milligrams, four times daily and a twice daily standard dose PPI for preferably 14 days. In practice, some common modifications are substitution of tetracycline with doxycycline, because tetracycline is expensive and may be out of stock.

00:04:40 Rachel Cole

And a lower dose of metronidazole, but both modifications may be associated with lower treatment success rates.

00:04:49 Rachel Cole

So we can usually recommend bismuth quadruple therapy first for treating H pylori, which uses four drugs: a PPI, Bismuth, tetracycline and metronidazole, especially for patients with a true penicillin allergy. Since it doesn't contain amoxicillin.

00:05:07 Rachel Cole

Or in patients who've used a macrolide in the past, since it also doesn't contain clarithromycin. That's because prior macrolide use could increase the risk of clarithromycin resistance, which is one of the main reasons those clarithromycin-based therapies have fallen out of favor.

00:05:26 Rachel Cole

So, regimens besides BQT may be needed in some cases due to issues such as cost, depending on what insurance we're dealing with, or lack of allergies,

00:05:37 Rachel Cole

A pill burden, or med availability. There are two regimens that contain the newer acid blocking drug vonoprazan or Voquezna, dual and triple packs, and a regimen containing the antibiotic rifabutin may be another option. And there are pros and cons to each regimen.

00:05:57 Rachel Cole

So let's walk through these.

00:06:01 Rachel Cole

Now the rifabutin triple therapy, or Talicia, contains the PPI omeprazole, and two antibiotics, amoxicillin and rifabutin.

00:06:11 Rachel Cole

So, it's a triple therapy treatment for H pylori in one capsule. Each capsule contains 10 milligrams Omeprazole, 250 milligrams of amoxicillin, and 12.5 milligrams of rifabutin, and the patient would take 4 capsules 3 times daily.

00:06:30 Rachel Cole

But with this rifabutin based triple therapy, you'll hear rifabutin has minimal resistance, which is under 5%, which is much less than macrolides like clarithromycin, or metronidazole or levofloxacin.

00:06:47 Rachel Cole

And I think for many of us, when we hear rifabutin, our mind immediately thinks about rifamycin type interactions and that is something to be aware of with rifabutin triple therapy or Talicia.

00:06:58 Rachel Cole

Even though it's just used for 14 days, we do want to watch for interactions since rifabutin's an inducer of cytochrome P450 3A4 enzymes. One key example is that Talicia can lower levels of most hormonal contraceptives, so we want to stay alert for patients taking an oral contraceptive.

00:07:19 Rachel Cole

Or using the patch ring or an implant and advise using backup contraception during treatment and for 28 days after. Since the effect can last after the Rifabutin is stopped.

00:07:33 Rachel Cole

Also be aware of some unique side effects with rifabutin and let patients know about these. For example, rifabutin can cause GI upset, can turn body fluids like tears and urine brown, orange, and can permanently stain soft contact lenses.

00:07:54 Rachel Cole

OK, so we've covered our rifabutin triple therapy. Now let's look at the regimens with the potassium competitive acid blocker, vonoprazan. If we look at what these combo products contain, the Voquezna dual pack contains 2 meds, vonoprazan 20 milligrams, and amoxicillin 500 milligram capsules.

00:08:14 Rachel Cole

The Voquezna Triple Pack contains 3 meds, so the same ingredients as the dual pack vonoprazan 20 milligram tabs and amoxicillin 500 milligram caps but also adds on clarithromycin 500 milligram tabs and the dosing schedule is also a bit different between the two.

00:08:34 Rachel Cole

So, what is a pharmacological consideration when prescribing the Voquezna triple pack? Well, because it contains clarithromycin, it's only suggested in the instance of proven antibiotic sensitivity because of the high resistance rates.

00:08:52 Rachel Cole

So, if we summarize some of our options here with rifabutin or Talicia triple therapy, it’s dosed as 4 capsules per dose 3 times daily with food which could be challenging for patients plus it costs about $840 without insurance for a 14-day course.

00:09:12 Rachel Cole

PCAB dual and triple packs or Voquezna carry a similar price tag to the rifabutin triple therapy.

00:09:19 Rachel Cole

PCAB dual is the least complex and the PCAB triple contains clarithromycin and may meet some significant resistance.

00:09:29 Rachel Cole

Bismuth quadruple therapy can be a good option, especially in patients with the true penicillin allergy, who must avoid amoxicillin or in patients who've previously used a macrolide, since it doesn't have clarithromycin and resistance is a concern.

00:09:45 Rachel Cole

Bismuth quadruple therapy costs about $530 for a 14-day course.

00:09:51 Rachel Cole

That may be more like $80 when substituting doxycycline for tetracycline, but some data suggest lower eradication rates with that switch, and again, some components are dosed 4 times daily and bismuth may be poorly tolerated. For example, it can cause Constipation.

00:10:14 Rachel Cole

So, because there's a multitude of options and considerations for each treatment option.

00:10:20 Rachel Cole

It's important to use shared decision making taking into consideration patient specific factors considering cost, adherence, interactions and side effects.

00:10:31 Rachel Cole

So, let's bottom line this, since this has been a lot to take in.

00:10:36 Rachel Cole

So optimized BQT is recommended in treatment naive or treatment experienced patients when antibiotic susceptibility is unknown or the patient has a true penicillin allergy. Consider substituting doxycycline for tetracycline in BQT if cost is a barrier for optimized BQT.

00:10:57 Rachel Cole

Consider PCAB dual therapy, which is our vonoprazan and amoxicillin in treatment, naive patients having difficulty managing BQT and avoid regimens with clarithromycin or levofloxacin unless susceptibility is confirmed.

00:11:15 Rachel Cole

Now let's talk through some adherence tips so patients have the best chance of successful adherence and eradication of the H pylori infection.

00:11:25 Rachel Cole

Engage with the patient and family, if possible, to help with complex regimens using phone call reminders, pill boxes and smartphone apps. Schedule their regimen. Talk to the patient about starting their regimen when they feel they'll have the most success. For example, if a patient has a vacation or business trip scheduled in the near future.

00:11:47 Rachel Cole

Perhaps starting the regimen after returning home would be more practical.

00:11:53 Rachel Cole

Let's review some practice pearls. So, PPIs are considered equally effective, so an equivalent dose of an alternate PPI can be used if needed.

00:12:03 Rachel Cole

Proactively educate the patient of side effects of their specific regimen and always be alert for allergies and especially penicillin allergies. Since many of these regimens contain amoxicillin.

00:12:16 Rachel Cole

It's important to stay alert for use as directed Sigs on combo products and check E prescription notes for any other directions to include on the prescription label. For example, patients getting rifabutin triple therapy or Talicia will take 4 capsules every 8 hours for 14 days.

00:12:37 Rachel Cole

Patients getting Voquezna dual pack will take one vonoprazan tablet twice daily, plus2 amoxicillin capsules 3 times a day for 14 days.

00:12:48 Rachel Cole

But those on Voquezna Triple Pack will take one vonoprazan tab, 2 amoxicillin capsules and one clarithromycin tab twice daily for 14 days.

00:13:00 Rachel Cole

Watch for any missing information on prescriptions for H pylori, since multiple meds with sometimes complex directions can lead to errors, since costs can vary widely. Help the patient work through any concerns and substitutions and engage with patients to help with adherence.

00:13:20 Rachel Cole

Double check quantities, review days’ supply and don't override drug interactions. And FYI, there's a combo pack known as Pylera, which has the components for BQT but provides only 10 days of therapy instead of the recommended 14 days.

00:13:39 Rachel Cole

So, this is a big topic to digest, and the treatment options may seem overwhelming. Fortunately, find our updated FAQ…

00:13:47 Rachel Cole

“H pylori from diagnosis to eradication” on our web page and also see our new H pylori treatment summary that contains the information from the table and the article with some additional details.

00:14:00 Narrator

We hope you enjoyed and gained practical insights from listening to this episode!

00:14:05 Narrator

We’ve linked the resources we mentioned—and more on today’s topic—right in the show notes. Those links will take you straight to Pharmacist’s Letter, Pharmacy Technician’s Letter, or Prescriber Insights, where you’ll find even more concise, evidence-based tools.

00:14:21 Narrator

If you’re not yet a subscriber, now’s the time—sign up today to stay ahead with trusted, unbiased insights, and continuing education. And as a listener, you can save 10% on a new subscription with code cc1025 at checkout.

00:14:37 Narrator

Have a question or a topic suggestion? Reach out using the ‘send us a text’ link in the show notes or email ContactUs@TRChealthcare.com - we love hearing from you.

00:14:48 Narrator

Thanks for listening… stay sharp, stay current—and we’ll catch you next time on Clinical Capsules!