Optimizing first line 7‐day standard triple therapy for Helicobacter pylori eradication: Prolonging treatment or adding bismuth: which is better?

OPTIMISING FIRST LINE SEVEN DAY STANDARD TRIPLE THERAPY FOR H.PYLORI ERADICATION: PROLONGING TREATMENT OR ADDING BISMUTH- WHICH IS BETTER? Running Title: Optimising therapy for H.pylori Alex Hwong-Ruey Leow1, Ahmad Najib Azmi2, Mun-Fai Loke3, Jamuna Vadivelu3, David Y Graham,4 Khean-Lee Goh1 1Division of Gastroenterology and Hepatology, Department of Medicine, 3Department of Medical Microbiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; 2 Faculty of Medicine and Health Sciences, University Science Islam Malaysia, Kuala Lumpur, Malaysia, 4 Baylor College of Medicine, Michael E. DeBakey VAMC, Houston, USA Correspondence: Professor Khean-Lee Goh Division of Gastroenterology and Hepatology Department of Medicine Faculty of Medicine 50603 Kuala Lumpur Malaysia Email: [email protected] ABSTRACT Objective: The 7-day standard triple therapy (STT) gives unacceptable low eradication rates. We sought to determine if extending the STT from 7 days to 14 days or adding a bismuth compound to the one week STT would result in a better eradication rates. Methods: H. pylori positive patients were assigned to: Group A- (7-day STT) rabeprazole(Pariet) 20mg b.i.d., amoxicillin(Ospamox) 1g b.i.d. and This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/1751-2980.12679 This article is protected by copyright. All rights reserved.

: clarithromycin(Klacid) 500mg b.i.d. for 7 days, Group B- (7 day STT with bismuth) rabeprazole (Pariet) 20mg b.i.d., amoxicillin (Ospamox) 1g b.i.d. and clarithromycin(klacid) 500mg b.i.d and bismuth subcitrate(De-Nol tab) 240mg b.i.d, for 7 days and Group C ( 14-day STT) rabeprazole (Pariet) 20mg b.i.d., amoxicillin (Ospamox) 1g b.i.d. and clarithromycin (Klacid) 500mg b.i.d. for 14 days (Group C). Eradication was tested for by the C13-UBT at least 4 weeks after the completion of therapy. Results: A total of 364 patients were recruited. In the intention-to-treat analysis, eradication rates were: 7 day STT- 79.3% (96/121)(95%CI:71.28-85.6), 7 day STT with bismuth-81.7%(98/120)(95%CI:73.8-87.6), 14 day STT- 88.6%(109/123)(95%CI:81.8-93.1) in group C. Statistical significance was achieved between the 7-day STT vs the 14-day STT (p=0.005). Conclusions: Adding bismuth to the 7 day STT did not result in an increase in eradication rate. Extending the STT to 14days however achieved a significantly higher eradication rate. However this did not achieve the targeted 90% eradication rate on ITT analysis. Key words: standard proton pump triple therapy, bismuth, H. pylori eradication This article is protected by copyright. All rights reserved.

: INTRODUCTION The 7 day standard triple therapy (STT) with proton pump inhibitor (PPI) and 2 antibiotics- amoxicillin and clarithromycin has been previously recommended as first line treatment for eradication of H.pylori infection by various consensus guidelines, [1-3]. However, the eradication success has decreased over the years. Although reported eradication rates vary with this treatment regimen, rates of less than 80% on intention-to-treat (ITT) analysis are nowadays quite typical [4]. The 7 day STT was first widely adopted in clinical practice in the late 1990s and was found to be efficacious, convenient and tolerable, ensuring a high compliance from patients [5,6]. But with the increasing use of antibiotics, bacterial resistance, especially to clarithromycin has increased across the world [7-9]. This has been thought to be the primary reason that treatment success with the one week STT has now decreased significantly [4]. The Maastricht V consensus guidelines have again highlighted this problem and has recommended against the use of clarithromycin in regions where the resistance rates exceeds 15% [10]. Graham et al, in line with the treatment of all other infectious diseases, has proposed that a higher eradication success target rate of at least 90-95% be adopted [11]. In Malaysia, we have shown that the STT for one week has not been effective with an ITT eradication rate of only 71.2% [12]. Clearly, recommended treatment regimens have to change. Although in clinical practice sequential and concomitant therapies have been used, they have not been popular with practising clinicians in Malaysia as they have found these regimens complex and difficult for patients to comply with. In this study, we sought to determine, in our local population, whether extending the STT from 7 days to 14 days or adding a bismuth compound to the one week STT would result in a better eradication rates in comparison to the one week STT. PATIENTS AND METHODS Patient selection This article is protected by copyright. All rights reserved.

: Consecutive patients diagnosed to have H. pylori infection for the first time, based on a positive rapid urease test (RUT) were recruited for the study. These patients had undergone outpatient upper gastrointestinal endoscopy performed for dyspepsia at the Endoscopy Unit, University of Malaya Medical Centre, Kuala Lumpur, from January 2013 to December 2015. Dyspepsia was defined as persistent or recurrent upper abdominal pain or discomfort over the preceding 3-months. Patients with significant concomitant medical illness, previous gastrointestinal surgery, pregnant/breastfeeding subjects as well as patients with known allergies to any component of the treatment regime especially to penicillin were excluded. Only patients who were receiving H. pylori treatment for the first time were included. Treatment failures were excluded. Following endoscopy, all subjects were categorized into four groups as follows: gastric ulcer (GU), duodenal ulcer (DU), both gastric and duodenal ulcers (GU/DU) and non-ulcer dyspepsia (NUD). Patients with complicated ulcers were excluded from the study. Informed consent was obtained from all patients before entering the study. The study protocol, patient information sheet and consent form were approved by the University of Malaya Medical Centre Ethics Committee and performed according to GCP-ICHC guidelines. Study design and treatment This study was a comparative, randomized, open labeled study. At gastroscopy, at least 2 antral and 2 body biopsies were taken from each subject and tested with the rapid urease test. A positive test was made when the urea solution had turned unequivocally red. This test has been previously validated in our local population [13]. All subjects were randomly assigned to three treatment groups: Group A: (7 day STT) - rabeprazole (Pariet, Eisai HHC, Tokyo, Japan)) 20mg b.i.d., amoxicillin (Ospamox, Biochemie, Austria)) 1g b.i.d. and clarithromycin (Klacid. Abbott laboratories, Chicago, USA)) 500mg b.i.d. for 7 days; Group B: (7 day STT with bismuth) - rabeprazole (Pariet) 20mg b.i.d., amoxicillin(Ospmaox) 1g b.i.d., bismuth This article is protected by copyright. All rights reserved.

: subcitrate (De-Nol tab, Astellas Pharma Ltd, Chertsey, Surrey, UK) 240mg b.i.d, and Group C: (14 day STT)- clarithromycin(Klacid) 500mg b.i.d for 7 days (Group B) and rabeprazole (Pariet) 20mg b.i.d., amoxicillin (Ospamox) 1g b.i.d. and clarithromycin (Klacid) 500mg b.i.d. for 14 days. All subjects were informed about the potential side effects of medications and the importance of completing the entire course of treatment. They were asked to return after 1 or 2 weeks after completion of therapy, to check for compliance to medications (defined as completing at least 85% of prescribed medications) and to report side effects experienced. Sample size calculation Based on an estimate of a 15% difference in eradication rates with a power of 80% and 2- sided significance level of 95%, a sample size of 110 per arm was computed. Determination of successful eradication All subjects were given a clinic follow-up and underwent 13C-Urea Breath Test (UBT) (IRIS, Analyser Wagner AnalysenTechnikTM, Worpswede, German) at least 4 weeks after completion of therapy. Successful eradication of H.pylori was defined as negative UBT. Eradication rates were calculated as for intention-to-treat (ITT) analysis and per- protocol (PP) analysis with 95% confidence intervals. We set a target of 90% eradication rate based on ITT analysis as an acceptable treatment level of treatment success –Grade B, based on Graham’s report card [11]. Statistical analysis All data were entered into SPSS (Statistical Packages for the Social Sciences, version 15, Chicago, IL, USA) program for analysis.. Fisher’s exact tests and chi square tests were used to compare categorical data. A two-tailed test was used in all analyses and P-value of <0.05 was considered statistically significant. This article is protected by copyright. All rights reserved.

: REULTS A total of 364 patients were recruited into the study. The breakdown of patients according to gender, peptic ulcer/non-ulcer and the mean age is as shown in Table 1. One hundred and twenty one patients were randomized to Group A (7 day STT), 120 to Group B (7 day STT with bismuth) and 123 to Group C (14 day STT) and were included in the Intention to teat analysis. In Group A, 5 patients had defaulted follow- up (3 not contactable by telephone, 2 did not come as promised) , in Group B, 2 patients had defaulted follow-up (all not contactable by telephone) and 3 patients were not compliant with medications and in Group C, 3 patients had defaulted follow- up (all not contactable by telephone) and 2 patients were not compliant to medications. Therefore, for per protocol analysis, 119, 116 and 115 patients were analyzed for Group A, B and C respectively. Treatment success On ITT analysis, H.pylori was eradicated in 79.3% of patients in group A, (96/121)(95%CI:71.3-85.6),81.7%(98/120)(95%CI:73.8-87.6) in group B and 88.6%(109/123)(95%CI:81.8-93.1) in group C (Table 1). Comparison between groups: ITT-analysis: p-values: Group B vs A-0.648;Group C vs A-0.005; Group C vs B- 0.127 PP analysis showed eradication rates of 82.8% of patients in group A (96/116)(95%CI:74.87-88.6),85.2%(98/115)(95%CI:77.60-90.6) in group B and 91.6%%(109/119)(95%CI:85.22-95.4) in group C. Comparison between groups: PP- analysis: p-values: Group B vs A-0.610;Group C vs A-0.042;Group C vs B-0.127. Patients with peptic ulcers were few. There were no significant differences in eradication rates of subjects with ulcers compared to non-ulcer dyspepsia group (NUD), p=1.00. Similarly, there were no significant differences in eradication rates between male and female subjects (p=0.38) This article is protected by copyright. All rights reserved.

: Side- effects and tolerability of treatment The treatment regimens were generally well tolerated. There were no significant differences in adverse events between all 3 treatment groups. In Group A, 17 (14.0%) complained of altered taste (dysgeusia), 5 (4.1%) patients of diarrhea,11 (6.6%) of abdominal pain and 3 (2.5%) of skin rash. The major complaint of patients in Group B was black stools- 18 (15.0%), 10 (8.3%) with altered taste and with a few patients complaining of abdominal pain and diarrhea. In Groups C, 23 (18.7%) patients complained of altered taste and 7 (5.7%) patients each complained of diarrhea and abdominal pain. All side -effects were reported as mild. The results are illustrated in Table 1. DISCUSSION Treatment success in all groups did not meet our target of 90% eradication rate on ITT analysis. Although numerically higher, adding bismuth to the STT did not reach statistical significance compared to the 7 day STT. Prolonging STT from seven to fourteen days resulted in a significantly higher eradication rate but this was also below 90% (88.6%). Our results were not confounded by weight and the proportion of patients who were smokers which was similar across all three treatment groups. The was also no difference in the ratio between patients with peptic ulcers and non-ulcer dyspepsia. The 7 day STT, as in many countries throughout the world, has been the recommended [14] treatment regimen in Malaysia for many years and is widely prescribed. Antibiotic susceptibility testing was not performed in our study. However, based on reports of very low or zero clarithromycin resistance in our local population [15], we have continued to use clarithromycin in our treatment regimens. Extending the duration of therapy has been shown in a worldwide systematic analysis, to result in a significant increase in eradication rate [16]. We have shown in our study, that treatment success was significantly increased compared to the 7 day STT. This article is protected by copyright. All rights reserved.

: However, we had hoped that the 14 day STT would have achieved our target eradication rate of 90% but our final result fell short of this. H.pylori has no resistance to bismuth compounds. In our other treatment arm, we added bismuth in standard doses to the 7 day STT. This did not achieve a better eradication compared to the 7 day STT. Graham and Dore have strongly recommended susceptibility testing for all patients subjected to H.pylori eradication therapy [17]. While testing for bacterial resistance, including molecular testing for clarithromycin resistance have been carried out in Malaysia, this is still not widely available. We have based our choice of antibiotics on our local resistance patterns. No resistance has been reported with amoxicillin [15]. Resistance to clarithromycin has consistently been low in Malaysia. Rates of 1.8%, 0, 6.8%, 1.2%, in 4 studies have been reported [15,18-20]. These studies have been conducted in the same locality as our study and it is therefore perplexing that we have not been able to achieve a higher eradication rate with our two week therapy. We were not able to carry out susceptibility testing on our patients bacterial strains in this study. There was a lack of improvement of treatment success with the addition of bismuth in our study. In a previous study by Sun et al [21], an eradication rate on ITT analysis of only 80% was achieved with a one week STT with bismuth. However, when this therapy was extended to two weeks, the eradication rate rose to 93.7% on ITT (p=0.01). Regrettably in our study we have not included an additional arm of bismuth STT extending to two weeks. In a recent study by Long et al [22], bismuth increased substantially the eradication rate of a two week PPI triple therapy with clarithromycin and metronidazole. In this pilot study, metronidazole was used in a q.i.d dose and bismuth at a higher dose of 600mg b.d with a high rate of adverse events reported. Based on our studies, better treatment regimens should be tested and used that can achieve a higher eradication rate of 90% or more on ITT analysis. This article is protected by copyright. All rights reserved.

: Declaration of Conflict of Interest KL Goh has served as a speaker and an advisory board member for Takeda Pharamceuticals and Eisai HHC. AHR Leow has served as a speaker for Eisai HHC. Eisai HHC Malaysia provided the supplies of rabeprazole for the study. There were no other conflict of interest. Acknowledgement Grant This study was supported by UM-MoEHIR UM.C/625/1/HIR/MoE/CHAN/13/2(HIR Account No:H-50001-A000032). REFERENCES 1. Malfertheiner P, Megraud F, O’Morain CA, et al. Management of Helicobacter pylori infection—the Maastricht IV/ Florence Consensus Report. Gut 2012;61:646–64. 2. Fock KM, Katelaris P, Sugano K,et al. Second Asia- Pacific Consensus Guidelines for Helicobacter pylori infection. J Gastroenterol Hepatol. 2009;24:1587-600 3. Chey WD, Wong BC. American College of Gastroenterology guideline on the management of Helicobacter pylori infection. Am J Gastroenterol 2007;102:1808-25. 4. Graham DY, Fischbach L. Helicobacter pylori treatment in the era of increasing antibiotic resistance. Gut. 2010;59:1143-53 5. Lind T, Veldhuyzen van Zanten S, Unge P, et al. Eradication of Helicobacter pylori using one-week triple therapies combining omeprazole with two antimicrobials: the MACH I Study. Helicobacter 1996;1:138-44. 6. Lind T, Megraud F, Unge P, et al. The MACH2 study: role of omeprazole in eradication of Helicobacter pylori with 1-week triple therapies. Gastroenterology 1999;116:248-53. 7. Horiki N, Omata F, Uemura M, et al. Annual change of primary resistance to clarithromycin among Helicobacter pylori isolates from 1996 through 2008 in Japan. Helicobacter 2009;14:86-90. This article is protected by copyright. All rights reserved.

: 8. Raymond J, Larmaque D, Kalach N, et al. High level antimicrobial resistance in French Helicobacter pylori isolates. Helicobacter 2010;15:21-7. 9. Megraud F, Coenen S, Versporten A, Kist M, Lopez-Brea M, Hirschl AM, Andersen LP, Goossens H, Glupczynski Y; Study Group participants. Helicobacter pylori resistance to antibiotics in Europe and its relationship to antibiotic consumption. Gut. 2013;62:34-42. 10. Malfertheiner P, Megraud F, O'Morain CA, Gisbert JP, Kuipers EJ, Axon AT, et al. Management of Helicobacter pylori infection- the Maastricht V/Florence Consensus Report. Gut. 2017;66:6-30. 11. Graham DY, Lu H, Yamaoka Y. A report card to grade Helicobacter pylori therapy. Helicobacter 2007;12:275-8. 12. Qua CS, Manikam J, Goh KL. Efficacy of 1-week proton pump inhibitor triple therapy as first-line Helicobacter pylori eradication regime in Asian patients: is it still effective 10 years on? J Dig Dis. 2010;11:244-8. 13. Goh KL, Parasakthi N, Peh SC, Puthucheary SD, Wong NW. The rapid urease test in the diagnosis of Helicobacter pylori infection. Singapore Med J. 1994; 35:161- 2. 14. Goh KL, Mahendraraj S, Parasakthi N, Kew St, Kandasami P, Mazlam Z. Management of Helicobacter pylori infection: Working Party Report of the Malaysian Society of Gastroenterology and Hepatology. Med J Malaysia 1998;53:302-10. 15. Goh KL, Navaratnam P. High Helicobacter pylori resistance to metronidazole but zero or low resistance to clarithromycin, levofloxacin, and other antibiotics in Malaysia. Helicobacter. 2011;16:241-5. 16. Yuan Y, Ford AC, Khan KJ, Gisbert JP, Forman D, Leontiadis GI, Tse F, Calvet X, Fallone C, Fischbach L, Oderda G, Bazzoli F, Moayyedi P Optimum duration of regimens for Helicobacter pylori eradication. Cochrane Database Syst Rev. 2013; 11:CD008337. 17. Graham DY, Dore MP. Helicobacter pylori therapy: a paradigm shift. Expert Rev Anti Infect Ther. 2016;14:577-85. This article is protected by copyright. All rights reserved.

: 18. Ho SL, Tan EL, Sam CK, Goh KL. Clarithromycin resistance and point mutations in the 23S rRNA gene in Helicobacter pyloriisolates from Malaysia. J Dig Dis. 2010 ;11:101-5. 19. The X, Khosravi Y, Lee WC, Leow AHR, et al. Functional and molecular surveillance of Helicobacter pylori antibiotic resistance in Kuala Lumpur. PLoS One. 2014;9:e101481. 20. Alfizah H, Norazah A, Hamizah R, Ramelah M. Resistotype of Helicobacter pylori isolates: the impact on eradication outcome. J Med Microbiol. 2014;63 (Pt 5):703-9. 21. Sun Q, Liang X, Zheng Q, Liu W, Xiao S, Gu W, Lu H. High efficacy of 14- day triple therapy-based, bismuth-containing quadruple therapy for initial Helicobacter pylori eradication. Helicobacter. 2010;15:233-8. 22. Long X, Chen Q, Yu L, Liang X, Liu W, Lu H. Bismuth improves efficacy of proton-pump inhibitor clarithromycin, metronidazole triple Helicobacter pylori therapy despite a high prevalence of antimicrobial resistance. Helicobacter. 2018:e12485.[Epub ahead of print] Table 1: Basic demographic data, eradication rates and side-effects Group A Group B Group C (7 day STT) (7 day STT & (14 day STT) Bismuth) Number of patients 121 120 123 Gender (male/female) 61/60 54/66 60/63 Mean Age (range) 54.00 (16-85) 53.0 (15-76) 58.0 (19-83) Weight kg (S.D.) 60.0 ± 13.5 61.8 ± 13.5 62.6 ± 14.2 Smoking 40/121(33.1%) 37/120 (30.8%) 42/123 (34.1%) Ulcer/Non-ulcer 5/116 6/114 5/118 Defaulters/Non- 5 5 4 compliance This article is protected by copyright. All rights reserved.

: Eradication rate ITT analysis* 79.3% (96/121) 81.7% (98/120) 88.6% (109/123) 95% C.I. 71.28-85.60 73.80-87.57 81.80-93.10 PP analysis** 82.8% (96/116) 85.2% (98/115) 91.6% (109/119) 95% C.I. 74.87-88.55 77.60-90.56 85.22-95.37 Side-effects Dysgeusia (n,%) 17 (14.0) 10 (8.3) 23 (18.7) Diarrhea 5 (4.1) 4 (3.3) 7 (5.7) Abdominal pain 11 (6.6) 3 (2.5) 7 (5.7) Skin rash 3 (2.5) 0 (0) 0 (0) Black stools 0 (0) 18 (15.0) 0 (0) * ITT analysis: 7 day STT vs 7 day STT with bismuth p=0.648; 7 day STT with bismuth vs 14 day STT p=0.127; 7 day triple vs 14 day triple therapy- p=0.048 **PP analysis: 7 day STT vs 7 day STT with bismuth p=0.610; 7 day STT with bismuth vs 14 days STT p=0.127; 7 day STT vs 14 day STT- p=0.042 This article is protected by copyright. All rights reserved.