H. pylori: ranitidine bismuth citrate leads to a higher cure rate than proton-pump inhibitors when added to clarithromycin and a nitroimidazole

Clinical bottom line (level 1a)

  1. Patients receiving H. pylori eradication therapy with clarithromycin and a nitroimidazole, who take ranitidine bismuth citrate compared with a proton-pump inhibitor were more likely to be cured (NNT = 20 at 4 weeks) .
  2. There was no clear difference in cure rates between ranitidine bismuth citrate and proton-pump inhibitors for patients given amoxicillin and clarithromycin.
Gisbert et al: Aliment Pharmacol Ther 2000; 14 : 1141-1150
Expires January 2004

The study

Systematic review of all randomised controlled trials of
  • Patients: Helicobacter pylori infection
  • Intervention: ranitidine bismuth citrate and 2 antibiotics (clarithromycin, amoxycillin or a nitorimidazole) for 1 week compared with proton-pump inhibitor (omeprazole, lansoprazole or pantoprazole) and 2 antibiotics for 1 week
  • Outcome: cure (13-C breath test or histology afer 4 weeks)

    Articles found in all languages using PubMed, to October 1999 (search terms: Helicobacter or pylori and clarithromycin, amoxicillin, amoxycillin, metronidazole, tinidazole, imidazole, nitroimidazole, omeprazole, lansoprazole, pantoprazole, proton pump inhibitor, 'proton pump', 7, seven, triple, week, weeks ) and hand-searching abstracts of major gastrointestinal conferences, and checking citations of selected articles and reveiews.

    Selection criteria: by 2 independent reviewers
    Appraisal criteria: see above and below
    Articles excluded if:
    • different antibiotics used in control arm


    12 RCTS found involving 1170 patients

    The evidence

    Outcome Time to outcome CER OR
    (95% CI)    		 NNT
    (95% CI)
    eradication (with clarithromycin and amoxicillin) 4 weeks /
    (73.7%)    		 1.15
    (0.80 to 1.64)     		38
    (NNT = 12 to infinity;
    NNH = 22 to infinity)
    eradication (with clarithromycin and a nitroimidazole) 4 weeks /
    (87.2%)    		 1.76
    (1.08 to 2.85)     		20
    (13 to 120)

    Citation

    1. Gisbert JP, Gonzalez L, Calvet X, et al: Helicobacter pylori eradication: proton pump inhibitor vs. ranitidine bismuth citrate plus 2 antibiotics for 1 week - a meta-analysis of efficacy. Aliment Pharmacol Ther 2000; 14 : 1141-1150
    Search Terms: from ACP Journal Club
    Contributor: Chris Ball, January 2002
    Reviewer:

    Clinical Question.
    Patient H. pylori infection
    Intervention or Exposure ranitidine bismuth citrate and antibiotics
    Comparison proton-pump inhibitor
    Outcome eradication
    		•