TASK № 12.

Specify the starting and alternative algorithms (in the case of failure of
initial treatment) for the pharmacotherapy of of gastric ulcer, allergy to
amoxicillin.

First line treatment ( Triple therapy )

1. Alcohol and smoking cessation

2. Removal of factors inducing psychoemotional stress
3. Dietary intervention

Medical intervention -

PPI
Amoxicillin ( In the case of an amoxicillin allergy, Metronidazole is chosen
instead )
Clarithromycin

First‐eradication regimen include a combination of omeprazole (20 mg b.d.),

clarithromycin (500 mg b.d.) and metronidazole (500 mg b.d.) for 7 days.

Second line treatment ( Quadruple therapy ) – 14 days

1. Bismuth salt
2. PPI
3. Antibiotic ( Metronidazole )
4. Tetracycline

Second‐line rescue regimen consisted of ranitidine bismuth citrate (RBC; 400 mg

b.d.) plus tetracycline (500 mg q.d.s.) and metronidazole (250 mg q.d.s.) for
7 days.

Third line treatment ( Individualized treatment )

1. Antibiotic drug sensitivity test

2. Bismuth Salt
3. PPT
4. Probiotics

For the third‐line rescue regimen, a combination with rifabutin (150 mg b.d.),
clarithromycin (500 mg b.d.) and omeprazole (20 mg b.d.) administered for
10 days.

Finally, a fourth‐line rescue regimen based on levofloxacin (500 mg b.d.),

clarithromycin (500 mg b.d.) and omeprazole (20 mg b.d.) prescribed for 10 
days.

Bismuth quadruple therapy consisting of a PPI, bismuth, tetracycline, and

a nitroimidazole for 10–14 days is a recommended first-line treatment
option. Bismuth quadruple therapy is particularly attractive in patients
with any previous macrolide exposure or who are allergic to penicillin
(strong recommendation, low quality of evidence).

Unlike clarithromycin triple therapy, the efficacy of bismuth quadruple

therapy is not affected by clarithromycin resistance. Further, although
metronidazole resistance does have an impact on the efficacy of bismuth
quadruple therapy, it is not nearly as profound as that of clarithromycin
resistance on clarithromycin triple therapy
Clarithromyclin Triple Therapy - The previous ACG guideline from 2007
recommended 14 days of treatment with a PPI, clarithromycin, and
amoxicillin (clarithromycin-based triple therapy) or—in patients with an
allergy to penicillin—metronidazole as an alternative to amoxicillin. At that
time, eradication rates for clarithromycin triple therapy were reported to be
70–85% and were highly influenced by the underlying rate of
clarithromycin resistance.