Lansoprazole + amoxicillin metronidazole

Proton pump inhibitor-based three-drug regimens Omeprazole 20 mg twice daily Clarithromycin 500 mg twice or lansoprazole 30 mg twice daily daily or pantoprazole 40 mg twice daily or esomeprazole 40 mg daily or rabeprazole 20 mg daily Bismuth-based four-drug regimens Amoxicillin 1 g twice daily or metronidazole 500 mg twice daily ... 

Esomeprazole, lansoprazole and omeprazole do not alter the pharmacokinetics of amoxicillin, and omeprazole does not alter bacampicillin bioavailability. Isolated reports describe glossitis, stomatitis and/or black tongue in a small number of patients when treated with lansoprazole and antibacterials, which included amoxicillin, clarithromycin and metronidazole. 

Thus, combinations of various PPIs, such as pantoprazole, lansoprazole, or omeprazole, used with clarithromycin and amoxicillin or metronidazole have all been reported to produce eradication rates and ulcer healing in excess of 90% and as high as 96%. An issue is the duration of therapy. It seems that 7 days of twice-daily combination therapy is required for effective eradication. Continued therapy with the PPI for 4 weeks is still suggested for ulcer healing, but some studies indicate that eradication is sufficient for ulcer healing, without the need for acid suppression. However, it is necessary to show a negative breath test within 1 week of therapy to enable this strategy. 

The treatment paradigm that is most frequently used is triple therapy with PPIs in combination with amoxicillin and clarithromycin. Usually this is a twice-daily treatment with omeprazole/lansoprazole/pantoprazole at standard dose with 1 g amoxicillin and 500 mg clarithromycin taken simultaneously, which in trials have given 90% eradication. Metronidazole may be used in substitution for either antibiotic. 

In trials so far performed with pantoprazole or lansoprazole, equivalent efficacy has been shown. It can be seen that any two of the three antibiotics in combination with omeprazole reach the eightieth percentile eradication. However, only those containing clarithromycin reach the ninetieth percentile. It is also clear that two antibiotics are ineffective, as is omeprazole alone. There is now more evidence that resistance to clarithromycin is increasing, and some instances of resistance to amoxicillin have been found. Metronidazole resistance is found rather frequently in those populations in which treatment with the nitroimidazoles for other diseases was prevalent. It must be admitted, however, that outside the clinical trial setting, eradication rates fall to approximately the seventieth percentile. Also, resistance to clarithromycin is also increasing. 

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