Background
Methods
Eligibility criteria
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Patient — studies of adult patients who were naïve to treatment (first-line therapy) or have previous treatment failures (second-line therapy).
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Intervention/Comparator — studies comparing any pharmacological regimens.
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Outcome measure — studies reporting pooled eradication rates measured by urea breathe testing or gastric mucosal biopsy four weeks after completion of treatment, as the primary outcome. Secondary outcome measures may include adverse events rates and rates of discontinuation of therapy due to severe adverse events.
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Design — systematic reviews and meta-analyses of data from randomized controlled trials (RCTs).
Exclusion criteria
Search strategy
Study selection
Data extraction
Quality assessment
Network meta-analysis (NMA)
Results
Results of search and selection
Systematic reviews included in analysis
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Triple therapy with different PPIs
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Triple therapy with different antibiotics
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Triple therapy versus bismuth-based therapy
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PPI versus H2RA in triple therapy
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Other drug therapies
Triple therapy with different PPIs
Author, year, country | Last search date | Disease | Interventionc
| Comparatorc
| No. of studies in MA | No. of patients in MA | Eradication rates | Eradication rates odds ratio (95 % CI) by ITT | Quality assessmentb
|
---|---|---|---|---|---|---|---|---|---|
Gisbert et al. 2003-r Spain [43] | Sep 2002 | HP infection; PUD/NUD/not reported | Rabeprazole | Omeprazole/Lansoprazole | 12 | 2226 | 79 % vs. 77 % | 1.15 (0.93–1.42) | + |
Rabeprazole | Omeprazole | 9 | 1475 | 77 % vs. 77 % | 1.03 (0.81–1.32) | ||||
Rabeprazole | Lansoprazole | 7 | 1095 | 82 % vs. 79 % | 1.20 (0.87–1.64) | ||||
Vergara et al. 2003 Spain [51] | Sep 2002 | HP infection | Omeprazole | Lansoprazole | 4 | 1085 | 74.7 % vs. 76 %; | 0.91 (0.69–1.21)a
| + |
Omeprazole | Rabeprazole | 4 | 825 | 77.9 % vs. 81.2 % | 0.81 (0.58–1.15)a
| ||||
Omeprazole | Esomeprazole | 2 | 833 | 87.7 % vs. 89 % | 0.89 (0.58–1.35)a
| ||||
Lansoprazole | Rabeprazole | 3 | 550 | 81 % vs. 85.7 % | 0.77 (0.48–1.22)a
| ||||
Gisbert et al. 2004 Spain [44] | Jun 2003 | HP infection; PUD +/−NUD | Esomeprazole | Omeprazole | 4 | 1292 | 85 % vs. 82 % | 1.19 (0.81–1.74) | + |
Gisbert et al. 2004 Spain [45] | Sep 2002 | HP infection; PUD +/−NUD | Pantoprazole | Omeprazole/Lansoprazole | 7 | 1137 | 83 % vs. 81 % | 1.00 (0.61–1.64) | + |
Pantoprazole | Omeprazole | 1 | 974 | 83 % vs. 82 % | 0.91 (0.49–1.69) | ||||
Pantoprazole | Lansoprazole | 2 | 258 | 78 % vs. 75 % | 1.22 (0.68–2.17) | ||||
Wang et al. 2006 China [24] | Jul 2006 | HP infection; DU, NUD, PUD | Esomeprazole | Omeprazole | 11 | 2048 | 85.6 % vs. 81.6 % | 1.30 (1.02–1.65) | 0 |
Wang X et al. 2006 China [46] | 2000–2005 (published date) | HP infection; PUD/NUD | Esomeprazole | Omeprazole/Pantoprazole | 11 | 2146 | 86 % vs. 81 % | 1.39 (1.09–1.75) | 0 |
Esomeprazole | Omeprazole | 10 | 1946 | 85 % vs. 82 % | 1.29 (1.01–1.65) | ||||
Esomeprazole | Pantoprazole | 1 | 200 | 94 % vs. 82 % | 3.44 (1.30–9.07) | ||||
McNicholl et al. 2012 Spain [42] | Oct 2011 | HP infection; naïve to therapy | Rabeprazole | Omeprazole/Lansoprazole/pantoprazole | 21 | 2945 | 80.5 % vs. 76.2 % | 1.21 (1.02–1.42) | 0 |
Esomeprazole | Omeprazole/Lansoprazole/pantoprazole | 12 | 2598 | 82.3 % vs. 77.6 % | 1.32 (1.01–1.73) | ||||
Rabeprazole | Esomeprazole | 5 | 1574 | 76.7 % vs. 78.7 % | 0.90 (0.70–1.17) |
Rank | Generation of PPI | PPI | Probability best (standard deviation) | OR (95 % credible Interval) Comparator: Omeprazole |
---|---|---|---|---|
1 | New | Esomeprazole | 0.820 (0.384) | 1.29 (1.08 – 1.56) |
2 | New | Rabeprazole | 0.170 (0.375) | 1.77 (0.99 – 1.39) |
3 | Old | Pantoprazole | 0.008 (0.087) | 0.94 (0.72 – 1.22) |
4 | Old | Lansoprazole | 0.003 (0.050) | 0.93 (0.74 – 1.16) |
5 | Old | Omeprazole | 0.0003 (0.018) | 1 |
Triple therapy with different antibiotics
Author, Year, country | Last search date | Disease | Countries of included RCTsc
| Intervention | Comparator | No. of studies in MA | No. of patients in MA | Eradication rates by ITT | Eradication rates odds ratio (95 % CI) by ITT | Quality assessmentb
|
---|---|---|---|---|---|---|---|---|---|---|
Zhang et al. 2008 China [25] | May 2008 | HP infection; naïve to treatment; PUD/NUD | China (8), Italy (3) |
Levofloxacin-containing triple: levofloxacin+ |
Standard triple: clarithromycin+ | 11 | 1926 | Not reported | 1.56 (1.25–1.94) | 0 |
+same PPI(Ome/panto/esome) + another one antibiotic (furazolidone/amoxicillin/azithromycin/metronidazole/tinidazole) | ||||||||||
Dong et al. 2009 China [33] | May 2009 | HP infection; naïve to treatment | China (4), Italy (5), Korea, Russia, France, Croatia, US |
Azithromycin-containing triple: azithromycin+ + one antibiotic (levofloxacin/amoxicillin/metronidazole)+ |
Azithromycin NOT-containing triple: + two antibiotics (amoxicillin/clarithromycin/metronidazole/tinidazole)+ | 14 | 1431 | 72.0 % vs. 69.8 % | 1.17 (0.64–2.14) | + |
+same PPI (ome/esome/lanso/panto) | ||||||||||
Yuan et al. 2009 China [34] | Dec 2008 | HP infection; naïve to treatment | Italy, Croatia, Turkey, China |
Moxifloxacin-containing triple: moxifloxacin+ |
Clarithromycin-containing triple: clarithromycin+ | 4 | 772 | 84.1 % vs. 73.6 % | 1.13 (1.01–1.27)a
| + |
+ same PPI (esome/lanso/ome) + another same regimen (amoxicillin/tinidazole/metronidazole/bismuth-) | ||||||||||
Zhang et al. 2013 China [47] | March 2012 | HP infection; PUD/NUD/others; either naive or with previous treatment failures | Korea (2), Croatia (2), China, Italy, Turkey |
Moxifloxacin-containing triple OR Quadruple: moxifloxacin + amoxicillin/metronidazole/tinidazole +/− RBC+ |
Standard triple or quadruple: (+/−)Bismuth/RBC + metronidazole/tinidazole/clarithromycin/amoxicillin+ | 7 | 1263 | 79.0 % vs. 68.3 % | 1.82 (1.17–2.81) | + |
+ same PPI (esome/ome/rabe/lanso) | ||||||||||
Croatia, Turkey, Italy |
First-line
|
First-line
| 3 | 717 | Not reported | 1.80 (0.71–4.55) | ||||
Moxifloxacin-containing triple OR Quadruple: moxifloxacin + amoxicillin/metronidazole/tinidazole (+/−) RBC+ |
Standard triple or quadruple: (+/−) Bismuth/RBC + metronidazole/tinidazole/clarithromycin/amoxicillin+ | |||||||||
+ same PPI (esome/lanso) | ||||||||||
Croatia, Korea (2), China |
Second-line
|
Second-line
| 4 | 546 | 73.3 % vs. 60.2 % | 1.78 (1.16–2.73) | ||||
Moxifloxacin-containing triple: moxifloxacin + metronidazole/amoxicillin+ |
Standard triple or quadruple: (+/−) Bismuth + metronidazole/tinidazole/clarithromycin+ | |||||||||
+ same PPI (esome/ome/rabe) | ||||||||||
Croatia, Korea (2), Turkey, Italy, China |
Moxifloxacin + amoxicillin (+/−) RBC+ |
Standard triple or quadruple: (+/−) Bismuth/RBC + metronidazole/tinidazole/clarithromycin/amoxicillin+ | 6 | 810 | Not reported | 1.50 (0.95–2.38) | ||||
+ same PPI(esome/ome/rabe/lanso) | ||||||||||
Croatia (2), Italy |
Moxifloxacin + metronidazole/tinidazole+
|
Standard triple or quadruple: (+/−) Bismuth/RBC + metronidazole/tinidazole/clarithromycin/amoxicillin+ | 3 | 453 | Not reported | 3.00 (1.84–4.89) | ||||
+ same PPI (esome/ome/rabe/lanso) | ||||||||||
Ye et al. 2014 China [35] | August 2013 | HP infection; naïve to treatment | Germany, Egypt, Taiwan (2), China (2), Spain (2), Italy (2) |
Levofloxacin-containing triple: levofloxacin+ |
Standard triple: clarithromycin+ | 10 | 2676 | 81.5 % vs. 77.2 % | 1.28 (0.88–1.85) | ++ |
+same PPI(Ome/lanso/esome) + another one antibiotic (amoxicillin/metronidazole) | ||||||||||
Peedikayil et al. 2014 Saudi Arabia [36] | March 2013 | HP infection; naïve to treatment | Egypt and Saudi Arabia, Taiwan (2), South Korea, China, Italy (2) |
Levofloxacin-containing triple: levofloxacin+ |
Standard triple: clarithromycin+ | 7 | 1782 | 79.1 % vs. 81.4 % | 0.97 (0.93–1.02)a
| + |
+same PPI(Ome/lanso/esome) + another one antibiotic (amoxicillin/+metronidazole/clarithromycin/azithromycin) | ||||||||||
Xiao et al. 2014 China [37] | March 2013 | HP infection; naïve to treatment, PUD/NUD/not reported | Italy (2), China (3), Spain (2), Egypt and Saudi Arabia, Korea |
Levofloxacin-containing triple: levofloxacin+ |
Standard triple: clarithromycin+ | 9 | 2512 | 80.2 % vs. 77.4 % | 1.03 (0.94–1.13)a
| ++ |
+same PPI(Ome/lanso/esome) + another one antibiotic (amoxicillin/+metronidazole/clarithromycin/azithromycin) | ||||||||||
Gou et al. 2014 China [26] | December 2013 | HP infection; naïve to treatment | All from China |
Levofloxacin-containing triple: levofloxacin+ |
Standard triple: clarithromycin+ | 21 | 2697 | 82.3 % vs.73.8 % | 1.12 (1.08–1.16)a
| 0 |
No details reported |
Triple therapy versus bismuth-based therapy
Author, Year, country | Last search date | Disease | Countries of included RCTsf
| Triple therapy | Bismuth-based Quadruple therapy | No. of studies in MA | No. of patients in MA | Eradication rates by ITT | Eradication rates odds ratio (95 % CI) by ITTd
| Quality assessmente
|
---|---|---|---|---|---|---|---|---|---|---|
Gene et al. 2003 Spain [38] | Aug 2002 | HP infection; naïve to therapy; PUD/NUD | Spain (2), US/Canada, unknown | PPI (ome/panto) + clarithromycin + amoxicillin | Bismuth + PPI(ome/panto) + tetracycline + metronidazole | 4 | 981 | 78 % vs. 81 % | 0.83 (0.61–1.14)a
| 0 |
Gisbert et al. 2005 Spain [27] | Sep 2004 | HP infection; NUD+/−PUD; previous treatment failures | Croatia, Spain (6), Belgium, Italy (4), Greece, China | PPI (ome/lanso/panto) + clarithromycin + amoxicillin/nitroimidazole | RBC + clarithromycin + amoxicillin
| 14 | 2205 | 78 % vs. 79 % |
Bismuth vs. triple 1.11 (0.88–1.40) | + |
Croatia, Italy (6), Spain, Norway, Unknown (2), The Netherlands, China | PPI (ome/lanso/panto/rabe) + clarithromycin + amoxicillin/nitroimidazole | RBC + clarithromycin + nitroimidazole
| 13 | 1777 | 80 % vs. 87 % |
Bismuth vs. triple 1.65 (1.15–2.37) | ||||
Taiwan, China, UK | PPI (ome) + clarithromycin + amoxicillin/nitroimidazole | RBC + nitroimidazole + amoxicillin
| 3 | 451 | 75 % vs. 73 % |
Bismuth vs. triple 0.92 (0.60–1.41) | ||||
Gisbert et al. 2006 Spain [28] | Jul 2005 | HP infection; Previous treatment failures | Italy (5), China, Spain, unknown |
Levofloxacin-containing: levofloxacin + PPI(panto/rabe/esome/ome) + amoxicillin/rifabutin | Bismuth + PPI(panto/rabe/ome) + tetracycline + metronidazole; or RBC+ tetracycline + metronidazole | 8 | 996 | 81 % vs. 70 % | 1.80 (0.9–3.5) | 0 |
Not reported |
Levofloxacin + amoxicillin + PPI(panto/rabe/esome/ome) | Bismuth + PPI(panto/rabe/ome) + tetracycline + metronidazole; or RBC+ tetracycline + metronidazole | not specified | Not specified | Not reported | 1.7 (0.71–4.0) | ||||
Saad et al. 2006 US [29] | Apr 2005 | HP infection; failed prior course(s) of standard triple therapy | Italy (5), China |
Levofloxacin-containing
: levofloxacin+ +amoxicillin+ | Bismuth − + metronidazole + tetracycline+ | 6 | 854 | 87 % vs. 60 % | 1.18 (1.08–1.29)b
| 0 |
+ same PPI (ome/esome/rabe/panto) | ||||||||||
Li et al. 2010 China [30] | 1981-Mar 2009 (Published date) | HP infection; previous treatment failures | Germany (2), Ireland |
Clarithromycin-containing: clarithromycin + amoxicillin+ | Bismuth+ +metronidazole + tetracycline+ | 3 | 411 | 46.5 % vs. 61.9 % | 0.53 (0.35–0.80) | 0 |
+ same PPI (ome/not specified) | ||||||||||
Korea (2), Croatia |
Moxifloxacin-containing: moxifloxacin + amoxicillin/metronidazole+ | Bismuth + metronidazole + tetracycline+ | 3 | 437 | Not reported | 1.78 (0.98–3.22) | ||||
+PPI(esome/ome) | ||||||||||
Taiwan, Korea, China (5), Italy (2) |
Levofloxacin-containing: levofloxacin + amoxicillin/rifabutin+ | Bismuth + metronidazole + tetracycline+ | 9 | 928 | Not reported | 1.43 (0.82–2.51) | ||||
+ same PPI(esome/panto/lanso/rabe) | ||||||||||
Luther et al. 2010 US [50] | 1990–2008 (Published date) | HP infection | Spain (2), Greece, Australia/New Zealand, India, US/Canada, Korea, Turkey, UK |
Clarithromycin-containing: clarithromycin + amoxicillin+ | Bismuth + metronidazole + tetracycline + | 9 | 1679 | 77.0 % vs. 78.3 % |
Bismuth vs. triple 1.00 (0.94–1.07b
| 0 |
+PPI (ome/panto/lanso/not specified) | ||||||||||
Wu et al. 2011 China [31] | Dec 2010 | HP infection; previous treatment failures | China (4), Korea (2), Croatia |
Moxifloxacin-containing: Moxifloxacin + + amoxicillin/metronidazole+ | Bismuth + metronidazole/furazolidone + tetracycline/amoxicillin/clarithromycin+ | 7 | 787 | 74.9 % vs. 61.4 % | 1.89 (1.38–2.58) | ++ |
+ PPI (esome/ome/rabe) | ||||||||||
Di Caro et al. 2012 UK [32] | Oct 2010 | HP infection; previous treatment failures | Italy (4), Spain (2), China (4), Korea (2), Taiwan, Unknown |
Levofloxacin + amoxicillin-containing: levofloxacin + amoxicillin + PPI(panto/rabe/esome/ome/lanso) | Bismuth quadruple therapy (not specified) | 14 | 1331 | 76.5 % vs. 67.4 % | 1.59 (0.98–2.58) | 0 |
Venerito et al. 2013 Germany [39] | Nov 2011 | HP infection; naïve to therapy; PUD/NUD/others | Spain (2), Australia/New Zealand, Greece, US/Canada, India, Korea, Turkey (2), UK, China, multi European countries |
Clarithromycin-containing: clarithromycin + amoxicillin+ | Bismuth + tetracycline + metronidazole+ | 12 | 2467 | 68.9 % vs. 77.6 % |
Bismuth vs. triple 0.06 (−0.01–0.13)c
| + |
+PPI(ome/panto/lanso/not specified) |
PPI versus H2RA in triple therapy
Author, year, country | Last search date | Disease | H2RAs | PPI | No. of studies in MA | No. of patients in MA | Eradication rates by ITT | Eradication rates odds ratio (95 % CI) by ITT | Quality assessmenta
|
---|---|---|---|---|---|---|---|---|---|
Gisbert et al. 2003 Spain [40] | Jan 2002 | HP infection; naïve to treatment; PUD/NUD | H2RAs (ranitidine/famotidine/nizatidine)+ | PPI (ome/lanso)+ | 20 | 2374 | 69 % vs. 74 % |
Triple vs. H
2
RAs 1.31 (1.09-1.58) | + |
+ two same antibiotics (amoxicillin/clarithromycin/metronidazole/tinidazole) +/− bismuth- | |||||||||
Graham et al. 2003 US [53] | 1990–2001 (Published date) | HP infection; either naïve or with previous treatment failures | H2RAs(nizatidine/famotidine/ranitidine) + | PPI (lanso/ome) + | 12 | 1441 | 78 % vs. 81 % | 0.83 (0.63–1.09) | 0 |
+ two same antibiotics (clarithromycin/amoxicillin/metronidazole/tinidazole) | |||||||||
H2RAs(not specified)+ |
Clarithromycin-containing triple
: Clarithromycin + PPI(not specified)+ | 6 | Not reported | 79 % vs. 69 % | 1.14 (0.76–1.71) | ||||
+ one same antibiotics (not specified) | |||||||||
H2RAs(not specified)+ |
Clarithromycin NOT-containing triple: PPI(not specified)+ | 6 | Not reported | 78 % vs. 85 % | 0.64 (0.45–0.92) | ||||
+two same antibiotics (not specified) | |||||||||
Ren et al. 2010 China [41] | Apr 2010 | HP infection; naïve to treatment |
Lafutidine-containing: H2RAs(lafutidine)+ |
Lanso-containing triple: PPI(lanso) + | 3 | 238 | 78 % vs. 77.5 % | 1.03 (0.64–1.66) | ++ |
+ two same antibiotics (clarithromycin + amoxicillin) |
Other drug therapies
Author, year, country | Last search date | Disease | Countries of included RCTsb
| Intervention | Comparison | No. of studies in MA | No. of patients in MA | Eradication rates by ITT | Eradication rates odds ratio (95 % CI) by ITT | Quality assessmenta
|
---|---|---|---|---|---|---|---|---|---|---|
Gisbert and Calvet 2012 Spain [48] | December 2011 | HP infection PUD/NUD/others | Germany, UK, Japan, Italy, Japan, Korea (2) | Concomitant therapy: metronidazole + standard triple therapy | Standard triple therapy | 7 | 984 | 90 % vs. 78 % | 2.36 (1.67–3.34) | 0 |
Note: Standard triple therapy: (PPI(ome/rabe/lanso) + amoxicillin + clarithromycin) | ||||||||||
Lv et al. 2015 China [49] | April 2014 | HP infection; PUD/NUD/others; naïve to treatment or had previous treatment | China (4), Taiwan (3), Korea, Turkey |
Quadruple regimens containing both amoxicillin and tetracycline
| Other quadruple regimens where amoxicillin and tetracycline were not contained together | 9 | 1453 | 78.1 % vs. 80.5 % | 0.90 (0.46–1.78) | + |
US, Italy, Turkey, Taiwan, China |
Triple therapy containing both amoxicillin and tetracycline
| Other regimens where amoxicillin and tetracycline were not contained together | 5 | 840 | 68.8 % vs. 66.7 % | 1.21 (0.64–2.28) | ||||
Nishizawa et al. 2014 Japan [54] | July 2014 | HP infection | Japan (5), Korea |
Rebamipide containing regimen: rebamipide+ |
Rebamipide NOT-containing regimen: none or mucosal protective agents other than rebamipide (teprenone/plaunotol)+ | 6 | 611 | 63.5 % vs. 52.7 % | 1.59 (1.14–2.22) | + |
+PPI(lanso/ome) + antibiotics (amoxicillin/metronidazole) |