Therapeutics

The Journal of Clinical Pharmacology

Effect of Dosing Schemes of Amoxicillin on 54(3) 258–266
© 2013, The American College of
Eradication Rates of Helicobacter pylori With Clinical Pharmacology
DOI: 10.1002/jcph.195
Amoxicillin‐Based Triple Therapy

Takahisa Furuta, MD, PhD1, Mitsushige Sugimoto, MD, PhD2,

Mihoko Yamade, MD, PhD2, Takahiro Uotani, MD2, Shu Sahara, MD2,
Hitomi Ichikawa, MD2, Takanori Yamada, MD, PhD2, Satoshi Osawa, MD, PhD2,
Ken Sugimoto, MD, PhD2, Hiroshi Watanabe, MD, PhD1,3,
and Kazuo Umemura, MD, PhD1,4

Abstract
Objectives: In standard regimens for Helicobacter pylori infection, amoxicillin is dosed twice daily, although the bactericidal effect of amoxicillin depends
on the %time‐above‐MIC. We aimed to examine whether dosing schemes of amoxicillin influenced eradication rates of amoxicillin‐based regimens.
Methods: One hundred eighty‐seven patients infected with clarithromycin‐sensitive strains of H. pylori were treated with PPI, clarithromycin 200 mg bid
and amoxicillin 750 mg bid, 500 mg tid or 500 mg qid for 1 week and 125 infected with clarithromycin‐resistant strains were treated with PPI,
metronidazole 250 mg bid and amoxicillin 750 mg bid, 500 mg tid or 500 mg qid for 1 week.
Results: Eradication rates (ITT) of the triple PPI/amoxicillin/clarithromycin therapy with bid, tid and qid dosings of amoxicillin were 77.8% (49/63), 93.5%
(58/62), and 91.9% (57/62), respectively. Those of the triple PPI/amoxicillin/metronidazole therapy were 80.5% (33/41), 90.5% (38/42), and 95.2% (40/42),
respectively. Eradication rates in regimens with tid and qid dosing of amoxicillin were higher than those of regimens with the bid dosing of amoxicillin.
Conclusions: The dosing scheme of amoxicillin significantly influenced eradication rates of triple therapies. Although amoxicillin is empirically dosed
twice daily, amoxicillin should be dosed at least three times daily in amoxicillin‐based triple therapies.

Keywords
H. pylori, amoxicillin, dosing scheme, eradication

The triple therapies with the twice daily dosing of a proton
pump inhibitor (PPI), amoxicillin, and clarithromycin or
metronidazole are the standard therapies for Helicobacter
pylori infection.1 The eradication rates with the triple
therapy with a PPI, amoxicillin and clarithromycin are
known to depend on susceptibility of H. pylori to
clarithromycin.2 However, this regimen cannot attain
the complete eradication even in patients infected with
clarithromycin‐sensitive strains of H. pylori. Similarly, the
eradication rates of the triple therapy with twice daily
dosing a PPI metronidazole and amoxicillin cannot attain
the sufficient eradication rates in most reports.
Drugs used in standard regimens for eradication of H.
pylori are usually dosed twice daily. Because plasma half‐
lives of clarithromycin and metronidazole are relatively
long and their bactericidal effects depend on Cmax/MIC and
AUC/MIC,3,4 twice daily dosing is appropriate for these
agents. However, the bactericidal effect of amoxicillin
depends on the percent time above MIC (%T > MIC), not
Cmax/MIC or AUC/MIC.5,6 The plasma half‐life of
amoxicillin is short.4 Therefore, twice daily dosing of
amoxicillin appears theoretically inappropriate and three or
four times daily dosing is thought to be a reasonable dosing
scheme for amoxicillin. As a matter of fact, the regimens
with four times‐daily dosing of amoxicillin could yield
higher eradication rates in patients refractory to the usual
standard regimens without 2nd antibiotic.7–9 On the other
hand, the twice daily dosing of amoxicillin could not attain
Abbreviations: CYP2C19, cytochrome P450 2C19; homEM, homozy-
gous extensive metabolizer of CYP2C19; hetEM, heterozygous exten-
sive metabolizer of CYP2C19; PM, poor metabolizer of CYP2C19;
PPI, proton pump inhibitor; H. pylori, Helicobacter pylori.
1
Center for Clinical Research, Hamamatsu University School of
Medicine, Hamamatsu, Japan
2
First Department of Medicine, Hamamatsu University School of
Medicine, Hamamatsu, Japan
3
Department of Clinical Pharmacology and Therapeutics, Hamamatsu
University School of Medicine,
4
Department of Pharmacology, Hamamatsu University School of
Medicine,
Submitted for publication 3 August 2013; accepted 22 September
2013.
Corresponding Author:
Takahisa Furuta, MD, PhD, Center for Clinical Research, Hamamatsu
University School of Medicine, 1‐20‐1, Handayama, Higashi‐Ku,
Hamamatsu 431‐3192, Japan
Email: furuta@hama-med.ac.jp
Furuta et al 259

sufficient eradication rates, even though higher dose of PPI
and amoxicillin was used.10 However, no study examined
the influence of dosing scheme of amoxicillin on the
eradication rates of H. pylori infection when used with
clarithromycin or metronidazole.
In the present study, we investigated whether the
different dosing schemes of amoxicillin influenced the
eradication rates of H. pylori with the regimens including
amoxicillin and clarithromycin or metronidazole. Our
results imply an important role of pharmacology of
antibiotics in the design of eradication regimen and
support the rationale of the frequent dosing scheme of
amoxicillin in the H. pylori eradication therapy.
Methods
This was a prospective, open label, randomized study. A
total of 312 patients infected with H. pylori infection were
invited to the study. Written informed consent was
obtained from each of the patients before the study and
the protocol was approved in advance by the Human
Institutional Review Board of Hamamatsu University
School of Medicine. Demographic clinical characteristics
of patients with different regimens groups were summa-
rized in Table 1.
Exclusion criteria were age <20 years; severe general
condition, such as renal insufficiency or liver dysfunction;
history of gastrectomy; inability to undergo eradication
therapy; allergy to agents used in this study; and serious
complications considered to prevent completion of the study.
Throughout the study period, the investigators who
assessed the status of H. pylori infection were unaware of
the patients’ clinical information.
The sample size was estimated in advance as follows:
in our previous study,11 the overall eradication rate
obtained with the triple therapy with 30 mg of lansopra-
zole bid, 200 mg of clarithromycin bid and 750 mg of
amoxicillin bid for 1 week was 81% in patients infected
with clarithromycin‐sensitive strains of H. pylori. In
contrast, the triple therapy with 30 mg of lansoprazole bid,
200 mg of clarithromycin tid and 500 mg of amoxicillin tid
for 1 week resulted in 97% of an eradication rate.
Therefore, the estimated sample size was no less than
59 per one group (a ¼ 0.05, 1  b ¼ 0.8). There was no
available comparative data on the eradication rates with
triple therapies with a PPI, metronidazole and amoxicillin
750 mg bid, 500 mg tid, or 500 mg qid for 1 week.
Schedule of the Examination of H. pylori Infection
Endoscopic examination and determination of H. pylori
infection were performed by rapid urease test (RUT)
(Helico Check. OTSUKA PHARMAEUTICAL CO.
LTD. Osaka Tokyo, Japan) before the treatment to
confirm the infection with H. pylori.
During the endoscopy, 5–10 mL of gastric juice
samples were collected by the trap located in the suction
line. DNAs were extracted from gastric juice samples
using the kit in the market acceding the manufacture’s
protocol (DNeasy Blood & Tissue Kit, Qiagen, Valencia,
CA). Whether H. pylori strains were sensitive or resistant
to clarithromycin was assessed by the measurement of
point mutations of 23S RNA gene at the positions of 2142
and 214312 by GeneCube® (Toyobo Ltd, Fukui, Japan)
according to the manufacture’s protocol.
At 1–2 months after the end of each of eradication
regimens, all patients underwent the [13C]‐urea breath test
as previously described for the judgment of success or
failure of eradication.13 When the results of [13C]‐urea
breath test indicated the absence of H. pylori infection,
patients underwent the gastroduodenoscopy for RUT to
confirm the absence of the infection. When both of [13C]‐
urea breath test and RUT yielded negative results, the
infection was judged to have been eradicated, but if one of
the tests yielded a positive result, failure to cure H. pylori
infection was diagnosed.
Eradication Regimens
We previously reported that pharmacogenomics‐based
tailored eradication therapy could yield higher eradication
rates in comparison with the empirical therapy.11 Our

Table 1. Demographic Clinical Characteristics of 312 Patients in Different Eradication Regimens

Triple PPI/AMPC/CAM therapy Triple PPI/AMPC/MNZ therapy

AMPC dosing 750 mg bid 500 mg tid 500 mg qid 750 mg bid 500 mg tid 500 mg qid

N 63 62 62 41 42 42
M/F 38/25 36/26 42/20 24/17 24/18 25/17
Age median (ranges), year 60 (37–84) 61 (25–85) 62 (26–80) 61 (31–88) 62 (23–89) 61 (36–77)
Smoker/non‐smoker 21/42 18/44 15/47 9/32 11/31 5/37
GU/DU/GDU/gastritis/others 13/9/2/31/8 11/8/1/38/4 8/4/1/47/2 8/10/0/18/5 7/7/1/23/4 5/3/0/30/4
CYP2C19 genotype group: homEM/hetEM/PM 21/32/10 26/29/7 24/30/8 14/16/11 11/25/6 24/17/1
Lansoprazole/rabeprazole 34/29 27/35 27/35 14/27 18/24 16/26

AMPC, amoxicillin; CAM, clarithromycin; M, male; F, female; GU, gastric ulcer; DU, duodenal ulcer; GDU, gastroduodenal ulcer; homEM, homozygous extensive
metabolizer of CYP2C19 ( 1/ 1); hetEM, heterozygous extensive metabolizer of CYP2C19 ( 1/ 2 or 1/3); PM, poor metabolizer of CYP2C19 ( 2/ 2,  2/ 3/, or  3/ 3).
260
pharmacogenomics‐guided tailored strategy was ap-
proved as the advances medicine by the Ministry of
Health, Labour and Welfare in Japan in 2007. Then, we
could perform the tailored therapy based on genotypes of
CYP2C19 and 23S rRNA of H. pylori.
When 23S rRNA gene of H. pylori at the position of
2142 or 2143 was wild type, patients were diagnosed to be
infected with strains sensitive to clarithromycin. When
23S rRNA gene was mutated at the position of 2142 or
2143, patients were diagnosed to be infected with strains
resistant against clarithromycin. Patients infected with
clarithromycin‐sensitive strains of H. pylori were treated
with the triple therapy with a PPI, clarithromycin 200 mg
bid and amoxicillin 750 mg bid, 500 mg tid or 500 mg qid
for 1 week. Patient infected with clarithromycin‐resistant
or unknown strains of H. pylori were treated with a PPI,
metronidazole 250 mg bid and amoxicillin 750 mg bid,
500 mg tid or 500 mg qid for 1 week. The dosing scheme
of amoxicillin was randomized by preallocated block
design (block size six) in each regimen.
The dosing scheme of a PPI was adjusted based on
CYP2C19 genotypes to minimize the influence of
CYP2C19 genotypes on the eradication rates, because the
eradication rates of the triple therapy in the homozygous
extensive metabolizers of CYP2C19 were lower in
comparison with those in the heterozygous extensive and
poor metabolizers of CYP2C19 when standard dose of a PPI
is used. Therefore, in homozygous extensive metabolizers
of CYP2C19, lansoprazole 30 mg or rabeprazole 10 mg was
dosed three times daily (tid), when amoxicillin was dosed
twice (bid) or three times daily (tid). When amoxicillin was
dosed four times daily (qid), lansoprazole 30 mg or
rabeprazole 10 mg was dosed four times daily (qid) in
homozygous extensive metabolizers of CYP2C19. How-
ever, in heterozygous extensive or poor metabolizers of
CYP2C19, lansoprazole 30 mg or rabeprazole 10 mg was
dosed twice daily irrespective of amoxicillin dosing
scheme. The ratio of lansoprazole to rabeprazole did not
differ among different eradication regimens.
Compliance with therapy was determined from the
interrogatory and the recovery of empty envelopes of
medications. Compliance less than 80% was considered as
poor compliance.
Statistics
Statistical differences in eradication rates among the
different regimens were assessed by Fisher’s exact test. All
statistical calculations were performed using SPSS (IBM®
SPSS® Statistics ver 20). P values < .05 were considered
as statistically significant.
Results
Of 312 patients, 186 were male and 126 were female. The
median age (with ranges) was 61 (23–89). Of them, 52
The Journal of Clinical Pharmacology / Vol 54 No 3 (2014)
were gastric ulcer, 41 were duodenal ulcer, 5 were
gastroduodenal ulcer, 187 were gastritis only, and
remaining 27 had other disorders such as gastric MALT
lymphoma, prevention for NSAID use and post‐endo-
scopic treatment of gastric cancer at the early stage.
Seventy‐one patients had ever failed in eradication therapy
and remaining 241 were naive for eradication therapy. Of
312 patients, 187 were infected with clarithromycin‐
sensitive strains of H. pylori and 125 were with
clarithromycin resistant strains. There were no significant
differences in median age, male/female ratio, disorder
types and smoking habit among different treatment
groups.
The flow of patients is demonstrated in Figure 1. A total
of 10 patients were excluded from the analyses because of
poor compliance and lost of follow up. There were no
discrepancy between 13C‐urea breath test and rapid urease
test after the treatment. All patients with the negative
results with 13C‐urea breath test after the treatment yielded
the negative results of rapid urease test afterward.
In the triple PPI/amoxicillin/clarithromycin therapy,
intention to treat (ITT) and per protocol (PP) analyses of
the eradication rates when amoxicillin was dosed at
750 mg bid, 500 mg tid and 500 mg qid were 77.8% (49/
63, CI ¼ 65.5–87.3%) and 80.3% (49/61, 95% CI ¼ 68.2–
89.4%), 93.5% (58/62, CI ¼ 84.3–98.2%) and 96.7% (58/
60, CI ¼ 88.5–99.6%), and 91.9% (57/62, CI ¼ 82.1–
97.3%) and 95.0% (57/60. CI ¼ 86.1–99.0%), respective-
ly. The eradication rate of amoxicillin 750 mg bid dosing
regimen was significantly lower in comparison with those
of 500 mg tid and 500 mg qid dosing regimens (P < .05
and <.05 for ITT, respectively and P  .001 and <.05,
respectively for PP). However, there were no significant
differences in eradication rates between tid and qid dosing
of amoxicillin (Figure 2).
The ITT and PP analyses of eradication rates by the
triple therapy with PPI, metronidazole 250 mg bid and
amoxicillin in patients infected with clarithromycin‐
resistant strains of H. pylori when amoxicillin was dosed
at 750 mg bid, 500 mg tid and 500 mg qid were 80.5% (33/
41, CI ¼ 65.1–91.2%) and 82.5% (33/40, CI ¼ 67.2–
92.7%), 90.5% (38/42, CI ¼ 77.4–97.3%) and 95.0% (38/
40, CI ¼ 83.1–99.4%) and 95.2% (40/42, CI ¼ 83.8–
99.4%) and 97.6% (40/41, CI ¼ 86.8–99.9%). The
eradication rate by the 750 mg bid regimen was
significantly lower than that by 500 mg qid regimen.
However, there were no significant differences in
eradication rates between tid and qid dosing of amoxicillin
(Figure 2).
There were no statistical significant differences in
eradication rates among three CYP2C19 genotype groups
in each regimen because PPI dose was individualized
based on CYP2C19 genotypes. In other words, PPI dosing
schemes differed among different CYP2C19 genotype
groups. Then, the eradication rates were sub‐analyzed
Furuta et al 261

Enrolled
n = 312

Susceptibility to CAM based on SNPs of 23S rRNA at 2142 and 2143

CAM-Sensitive CAM-Resistant
n = 187 n = 125

PPI PPI PPI PPI PPI PPI

+ CAM 200 mg bid + CAM 200 mg bid + CAM 200 mg bid + MNZ 250 mg bid + MNZ 250 mg bid + MNZ 250 mg bid
+ AMPC 750 mg bid + AMPC 500 mg tid + AMPC 500 mg qid + AMPC 750 mg bid + AMPC 500 mg tid + AMPC 500 mg qid
n = 63 n = 62 n = 62 n = 41 n = 42 n = 42

Lost of follow up Lost of follow up Lost of follow up Lost of follow up Lost of follow up Poor compliance
n=1 n=1 n=2 n=1 n=2 n=1

Poor compliance Poor compliance

n=1 n=1

n = 61 n = 60 n = 60 n = 40 n = 40 n = 41

13C-UBT

Figure 1. The flow of 312 patients enrolled to the study. A total of 187 patients were infected with clarithromycin (CAM)‐sensitive strain of H. pylori
based on analysis of 23S reran at positions of 2142 and 2143 and were randomly assigned to either of three clarithromycin‐based regimens with different
amoxicillin dosing schemes. The remaining 125 patients were diagnosed to be infected with clarithromycin‐resistant strains of H. pylori and were
randomly assigned to either of three metronidazole‐based regimens with different amoxicillin dosing schemes.

based on CYP2C19 genotype groups. ITT and PP analyses
of eradication rates in homozygous extensive metabo-
lizers, heterozygous extensive metabolizers and poor
metabolizers of CYP2C19 are summarized in Figure 2.
Because of small number of each group after classification
to CYP2C19 genotype groups, the statistical differences
were not observed in all genotype groups. However,
eradication rates seemed to increase from twice to three or
four times daily dosing of amoxicillin in all sub‐analyzed
groups (Figure 3).
No severe adverse events were observed. Mild adverse
events were observed as summarized in Table 2. There
were no statistically significant differences in the
incidences in the adverse events among the amoxicillin
750 mg bid, 500 mg tid and 500 mg qid regimens.
Discussion
In the present study, we found that the dosing scheme of
amoxicillin influenced the eradication rates in the triple
therapies such as the triple PPI/amoxicillin/clarithromycin
therapy and the triple PPI/amoxicillin/metronidazole
therapy and that an increase of dosing frequency of
amoxicillin from twice daily to three or four times daily
improved the eradication rates, but did not increase the
incidence of adverse events. Therefore, amoxicillin should
be dosed three or four times daily in the H. pylori
eradication therapy.
Antibiotics have 2 different pharmacodynamic classi-
fications. Time dependent killing depends on the % time
above MIC (%T > MIC). Concentration dependent killing
depends on Cmax (maximum plasma concentration/
minimum inhibitory concentration)/MIC or AUC (area
under the plasma concentration time‐curve)/MIC.14 Most
antimicrobial agents in the latter type, such as clarithro-
mycin, metronidazole and fluoroquinolones, have longer
plasma half‐life and post‐antibiotic effect (PAE) defined
as the bacterial growth suppression which persists after a
limited exposure to an antimicrobial agent,15 once or twice
daily dosing is appropriate. On the other hand, amoxicillin
is a time dependent killing antibiotic.16 The plasma half‐
life of amoxicillin is approximately 1 hour. Moreover,
amoxicillin has little PAE on gram‐negative rods, such as
H. pylori.16,17 Therefore, theoretically amoxicillin should
be dosed frequently (e.g., three or four times daily) to
make %T > MIC longer (Figure 4). In the present study,
we demonstrated that as dosing scheme of amoxicillin was
changed from 750 mg bid to 500 mg tid or 500 mg qid, the
eradication rates were increased.
In the dual therapy with a PPI and amoxicillin, the
eradication rate depend on the dosing scheme of
amoxicillin. In the reports where eradication rates higher
262 The Journal of Clinical Pharmacology / Vol 54 No 3 (2014)

P < 0.05
A P < 0.05

P < 0.05 P ≥ 0.05 P < 0.05 P ≥ 0.05

100
Eradication rate (%)
80

8.5% - 99.6%)

6.1% - 99.0%)
93.5% (58/62, CI = 84.3% - 98.2%)

% - 89.4%)
91.9% (57/62, CI = 82.1%--97.3%)
77.8% (49/63, CI = 65.5%-87.3%)
60

96.7% (58/60, 95% CI = 88

95.0% (57/60, 95% CI = 86

80.3% (49/61, 95% CI = 68.2%
40

20

0
ITT PP
AMPC 750 mg bid AMPC 500 mg tid AMPC 500 mg qid

Triple PPI/CAM/AMPC therapy

P < 0.05 P < 0.05

B P < 0.05 P ≥ 0.05 P ≥ 0.05

P ≥ 0.05
100
Eradication rate (%)

80
95.2% (40/42, CI = 83.8%-99.4%)

% (40/41, CI = 86.8% - 99.9%)

82.5% ((33/40, CI = 67.2% - 92.7%)
38/42, CI = 77.4% - 97.3%)
33/41, CI = 65.1% - 91.2%)

38/40, CI = 83.1% - 99.4%)

60

40

20
80.5% (3

90.5% (3

95.0% (3

97.6%

0
ITT PP
AMPC 750 mg bid AMPC 500 mg tid AMPC 500 mg qid
Triple PPI/MNZ/AMPC therapy
Figure 2. Intention to treat (TT) and per‐protocol (PP) analyses of eradication rates of regimens with different dosing scheme of amoxicillin in the triple
PPI/clarithromycin/amoxicillin therapy (Triple PPI/CAM/AMPC therapy) (A) and the triple PPI/metronidazole/amoxicillin therapy (Triple PPI/MNZ/
AMPC therapy) (B).

than 80% were attained, amoxicillin was dosed four times four times daily dosing in both clarithromycin‐based and
daily.8,9,18–20 However, in the reports where amoxicillin metronidazole‐based regimens. Therefore, three times
was dosed twice daily, the eradication rates did not reach daily dosing appeared appropriate for amoxicillin when it
80%.21 These reports suggest that amoxicillin should be is dosed with clarithromycin or metronidazole. However,
dosed frequently to exert its bactericidal effect sufficiently generally, an increase of the number of daily doses of
by making the %T > MIC longer. medicines sometimes leads to the lower compliance. In the
In the present study, the eradication rate was insuffi- present study, patients received detailed and elaborate
cient when amoxicillin was dosed twice daily, whereas explanation from doctors and pharmacists. Then, we could
when amoxicillin was dosed three times or four times achieve relatively higher compliance. Because dosing
daily, sufficient eradication rates were attained. However, times of amoxicillin influence the eradication rates,
the eradication rates by the regimens with three times daily detailed and elaborate explanation on the medication to
dosing of amoxicillin were almost the same as those with patients is needed for them to keep the high compliance.
Furuta et al 263

A ITT PP
P < 0.05

100

80

95.8% (CI = 78.9% - 99.9%, 23/24)

100.0%, 23/23)

100.0%, 28/28)
97.6%, 23/26)

9.3% - 96.2%)
99.9%, 28/29)

9.0%, 23/25)
1.8%, 16/21)

0.7%, 25/32)

0.7%, 25/32)

7.8%, 26/29)
100.0%, 7/7)

100.0%, 8/8)

100.0%, 7/7)

100.0%, 8/8)
7.5%, 8/10)

7.5%, 8/10)
84.2% (CI: 60.4%-96.6%, 16/19)
60
88.5% (CI = 69.8% - 9
76.1% (CI = 52.8%-91

78.1% (CI = 60.0%-90

80.0% (CI = 44.4%-97

100.0% (CI = 65.2%-1

100.0% (CI = 68.8%-1

92.0% (CI = 74.0%-99

100.0% (CI = 87.8%-1

78.1% (CI = 60.0%-90

100.0% (CI = 89.9%-1

89.7% (CI = 72.6%-97

80.0% (CI = 44.4%-97

100.0% (CI = 65.2%-1

100.0% (CI = 68.8%-1

86.7% (26/30, CI = 69
40 96.6% (CI = 82.2% - 9

20

0
h EM
homEM h tEM
hetEM PM h EM
homEM h tEM
hetEM PM

AMPC 750 mg bid AMPC 500 mg tid AMPC 500 mg qid

Triple PPI/CAM/AMPC therapy

B ITT PP
P < 0.05 P < 0.05

100

80
5%)
4)

4)
1)

6)
0% (CI: 88.3%-100.0%, 24/24

88.2% (15/17, CI = 63.6% - 98.5

0% (CI: 88.3%-100.0%, 24/24

78.6% (CI = 49.2%-95.3%, 11/14))

87.5% (CI = 61.7%-98.4%, 14/16))

78.6% (CI = 49.2%-95.3%, 11/14))

87.5% (CI = 61.7%-98.4%, 14/16))

93.8% (CI = 69.8%-99.8%, 15/16))

81.8% (CI = 48.3%-97.7%, 9/11

83.3% (CI = 35.9% - 99.6%, 5/6

0% (CI = 54.9%-100.0%, 5/5))

% (CI = 39.0% - 94.0%, 8/11)

0% (CI = 5.0%-100.0%, 1/1)

0% (CI = 5.0%-100.0%, 1/1)

90.0% (CI = 55.5%-99.7%, 9/10)

80.0% (CI = 44.4%-97.5%, 8/10)

96.0% (CI: 79.6%-99.9%, 24/25)

96.0% (CI: 79.6%-99.9%, 24/25)

60

40

20
72.7%
100.0

100.0

100.0

100.0
100.0

0
homEM hetEM PM homEM hetEM PM

AMPC 750 mg bid AMPC 500 mg tid AMPC 500 mg qid

Triple PPI/MNZ/AMPC therapy
Figure 3. Intention to treat (TT) and per‐protocol (PP) analyses of eradication rates of regimens with different dosing scheme of amoxicillin in the triple
PPI/clarithromycin/amoxicillin therapy (Triple PPI/CAM/AMPC therapy) (A) and the triple PPI/metronidazole/amoxicillin therapy (Triple PPI/MNZ/
AMPC therapy) (B) in different CYP2C19 genotype groups. homEM, homozygous extensive metabolizers of CYP2C19 ( 1/ 1), hetEM, heterozygous
extensive metabolizers of CYP2C19 ( 1/ 2 or  2/ 3). PM, poor metabolizers of CYP2C19 ( 2/ 2,  2 3 or  3/ 3).

The optimal selection of antimicrobial agent based on the eradication rates. Therefore, one has to use the optimal
results of susceptibility of each H. pylori strain to antimicro- antimicrobial agents in an optimal dosing scheme.
bial agents is an important strategy to attain the higher In the present study, we increased the dose of a PPI in
eradication rates.22 Then, we used clarithromycin only in homozygous extensive metabolizers of CYP2C19, be-
patients infected with clarithromycin‐sensitive strains of cause in our previous report,18 the eradication rate in the
H. pylori. However, we found that the number of doses daily homozygous extensive metabolizers did not reach 90% in
of amoxicillin was also important for the improvement of patients infected with clarithromycin‐sensitive strains of
264 The Journal of Clinical Pharmacology / Vol 54 No 3 (2014)

Table 2. Incidence of Adverse Events

Triple PPI/AMPC/CAM therapy Triple PPI/AMPC/MNZ therapy

AMPC dosing 750 mg bid 500 mg tid 500 mg qid 750 mg bid 500 mg tid 500 mg qid

Loose stool 10 12 9 5 6 8
Diarrhea 2 1 0 2 2 1
Abdominal pain 2 0 0 0 0 1
Allergic reaction 3 0 0 1 0 0
Others 2 0 0 1 2 1

PPI, proton pump inhibitor; AMPC, amoxicillin; MNZ, metronidazole.

H. pylori by the triple therapy with lansoprazole 30 mg
bid, clarithromycin 200 mg tid and amoxicillin 500 mg tid.
Thus, we increased the dose of a PPI in homozygous
extensive metabolizers. As a result of the CYP2C19
genotype‐guided dose setting of a PPI, there were no
statistically significant influences of CYP2C19 genotypes
on the eradication rates.
The doses of clarithromycin and metronidazole used in
this study were 200 mg bid and 250 mg bid, respectively.
These doses appeared lower in comparison with those

750 mg 750 mg
A
concentration of amoxicillin
hm of plasma
Logarith

MIC

500 mg 500 mg 500 mg

B
ation of amoxicillin
m of plasma
Logarithm
concentra

MIC

500 mg 500 mg 500 mg 500 mg

C
on of amoxicillin
Logarithm off plasma
concentratio

MIC

Figure 4. Schematic model of Time Above MIC (T > MIC) of amoxicillin dosed at 750 mg twice (A), 500 mg three times (B) or 500 mg four times daily
(C). As the dosing frequency is increased, a total length of %time above MIC (indicated with $) is increased.
Furuta et al
used in European countries and USA (i.e., clarithromycin
500 mg bid and metronidazole 500 mg bid). The clinical
trials performed in Japan indicated that clarithromycin
200 mg bid and metronidazole 250 mg bid were each
enough for Japanese patients.20,23,24 There seem ethnic
differences in the optimal doses of antimicrobial agents
used in H. pylori eradication therapy.
Lastly, our results must be interpreted within the study
limitations as follows; Firstly, we did not measure the
plasma amoxicillin concentrations in patients. Therefore,
we could not correlate the pharmacokinetic disposition of
amoxicillin with the eradication rates. However, plasma
half‐life of amoxicillin is so short that %T > MIC of
amoxicillin in patients treated with amoxicillin dosed three
or four times daily must be longer than that in patients
treated with amoxicillin dosed twice daily. Secondly, the
sample size seemed small especially when data were
analyzed in different genotype subgroups. All P‐values
were not so low. Thirdly, we did not measure  17 allele
because incidence of  17 in our ethnic group is very low.25
However, the clinical relevance of  17 allele in PPI
therapy remains to be determined.26 Finally, this is the
single center study. Therefore, we have to consider the
present study results as preliminary and a further larger
multicenter study is needed, where plasma levels of
amoxicillin must be measured.
In conclusion, dosing scheme of amoxicillin affects the
eradication rates of H. pylori. The twice daily dosing of
amoxicillin is thought to be insufficient for amoxicillin to
exert its bactericidal effect sufficiently. At least three‐
times daily dosing is recommended for amoxicillin when it
is used with clarithromycin or metronidazole in the triple
therapy. In some recent reports of H. pylori eradication
therapy, new antimicrobial agents have been tested to
attain further higher eradication rates. However, the
dosing scheme of antimicrobial agents should be
reconsidered from the viewpoint of pharmacology of
antimicrobial agents. We must not forget that most H.
pylori are susceptible to amoxicillin and this agent should
be used skillfully and cleverly with reference to the
pharmacology of antibiotics.
Acknowledgement
The assistance of the endoscopy staff is greatly appreciated.
Declaration of Conflict of Interest
The Center for Clinical Research and the First Department
of Medicine at Hamamatsu University School of Medicine
have received grants from Takeda Pharmaceutical Co.,
Ltd, AstraZeneca KK, Eisai Co., Ltd, Daiichi‐Sankyo Co.
Ltd., and Dr. Furuta and Dr. Sugimoto have received
lecture fees from those companies. The authors have no
other conflicts of interest that are directly relevant to the
content of this article.
265
Funding
This study was partly supported by grants‐in‐aid for Scientific
Research from the Ministry of Education, Culture, Science, and
Sports of Japan (23590913).
References
1. Fock KM, Katelaris P, Sugano K, et al. Second Asia‐Pacific
consensus guidelines for Helicobacter pylori infection. J Gastro-
enterol Hepatol. 2009;24:1587–1600.
2. Murakami K, Sato R, Okimoto T, et al. Eradication rates of
clarithromycin‐resistant Helicobacter pylori using either rabeprazole
or lansoprazole plus amoxicillin and clarithromycin. Aliment
Pharmacol Ther. 2002;16:1933–1938.
3. Mainz D, Borner K, Koeppe P, Kotwas J, Lode H. Pharmacokinetics
of lansoprazole, amoxicillin and clarithromycin after simultaneous
and single administration. J Antimicrob Chemother. 2002;50:699–
706.
4. Klotz U. Pharmacokinetic considerations in the eradication of
Helicobacter pylori. Clin Pharmacokinet. 2000;38:243–270.
5. Craig WA. Basic pharmacodynamics of antibacterials with clinical
applications to the use of beta‐lactams, glycopeptides, and linezolid.
Infect Dis Clin North Am. 2003;17:479–501.
6. Craig WA. Proof of concept: performance testing in models. Clin
Microbiol Infect. 2004;10(Suppl 2):12–17.
7. Furuta T, Sugimoto M, Kodaira C, et al. The dual therapy with 4
times daily dosing of rabeprazole and amoxicillin as the 3rd rescue
regimen for eradication of H. pylori. Hepatogastroenterology.
2010;57:1314–1319.
8. Furuta T, Shirai N, Xiao F, et al. High‐dose rabeprazole/amoxicillin
therapy as the second‐line regimen after failure to eradicate H. pylori
by triple therapy with the usual doses of a proton pump inhibitor,
clarithromycin and amoxicillin. Hepatogastroenterology.
2003;50:2274–2278.
9. Miehlke S, Kirsch C, Schneider‐Brachert W, et al. A prospective,
randomized study of quadruple therapy and high‐dose dual therapy
for treatment of Helicobacter pylori resistant to both metronidazole
and clarithromycin. Helicobacter. 2003;8:310–319.
10. Isomoto H, Inoue K, Furusu H, et al. High‐dose rabeprazole‐
amoxicillin versus rabeprazole‐amoxicillin‐metronidazole as sec-
ond‐line treatment after failure of the Japanese standard regimen for
Helicobacter pylori infection. Aliment Pharmacol Ther. 2003;18:
101–107.
11. Furuta T, Shirai N, Kodaira M, et al. Pharmacogenomics‐based
tailored versus standard therapeutic regimen for eradication of
H. pylori. Clin Pharmacol Ther. 2007;81:521–528.
12. Versalovic J, Osato MS, Spakovsky K, et al. Point mutations in the
23S rRNA gene of Helicobacter pylori associated with different
levels of clarithromycin resistance. J Antimicrob Chemother.
1997;40:283–286.
13. Kato M, Asaka M, Ohara S, Toyota T. Clinical studies of 13C‐urea
breath test in Japan. J Gastroenterol. 1998;33(Suppl 10):36–39.
14. Furuta T, Graham DY. Pharmacologic aspects of eradication therapy
for Helicobacter pylori Infection. Gastroenterol Clin North Am.
2010;39:465–480.
15. Alados JC, Gutierrez J, Garcia F, Liebana J, Piedrola G. Post‐
antibiotic effect of three quinolones against gram negative isolates
from urine. Med Lab Sci. 1990;47:272–277.
16. Sorberg M, Hanberger H, Nilsson M, Nilsson LE. Pharmaco-
dynamic effects of antibiotics and acid pump inhibitors on
Helicobacter pylori. Antimicrob Agents Chemother. 1997;41:
2218–2223.
17. Hassan IJ, Stark RM, Greenman J, Millar MR. Absence of a post‐
antibiotic effect (PAE) of beta‐lactams against Helicobacter pylori
NCTC 11637. J Antimicrob Chemother. 1998;42:661–663.
266
18. Furuta T, Shirai N, Takashima M, et al. Effect of geno-
typic differences in CYP2C19 on cure rates for Helicobacter
pylori infection by triple therapy with a proton pump inhibitor,
amoxicillin, and clarithromycin. Clin Pharmacol Ther. 2001;
69:158–168.
19. Furuta T, Shirai N, Takashima M, et al. Effects of genotypic
differences in CYP2C19 status on cure rates for Helicobacter pylori
infection by dual therapy with rabeprazole plus amoxicillin.
Pharmacogenetics. 2001;11:341–348.
20. Shirai N, Sugimoto M, Kodaira C, et al. Dual therapy with high doses
of rabeprazole and amoxicillin versus triple therapy with rabepra-
zole, amoxicillin, and metronidazole as a rescue regimen for
Helicobacter pylori infection after the standard triple therapy. Eur J
Clin Pharmacol. 2007;63:743–749.
21. Graham DY, Javed SU, Keihanian S, Abudayyeh S, Opekun AR.
Dual proton pump inhibitor plus amoxicillin as an empiric anti‐H.
pylori therapy: studies from the United States. J Gastroenterol.
2010;45:816–820.
The Journal of Clinical Pharmacology / Vol 54 No 3 (2014)
22. Kawai T, Yamagishi T, Yagi K, et al. Tailored eradication
therapy based on fecal Helicobacter pylori clarithromycin sensi-
tivities. J Gastroenterol Hepatol. 2008;23(Suppl 2):S171–S174.
23. Murakami K, Sato R, Okimoto T, et al. Efficacy of triple therapy
comprising rabeprazole, amoxicillin and metronidazole for second‐
line Helicobacter pylori eradication in Japan, and the influence of
metronidazole resistance. Aliment Pharmacol Ther. 2003;17:119–
123.
24. Asaka M, Sugiyama T, Kato M, et al. A multicenter, double‐blind
study on triple therapy with lansoprazole, amoxicillin and
clarithromycin for eradication of Helicobacter pylori in Japanese
peptic ulcer patients. Helicobacter. 2001;6:254–261.
25. Sugimoto K, Uno T, Yamazaki H, Tateishi T. Limited frequency of
the CYP2C19 17 allele and its minor role in a Japanese population.
Br J Clin Pharmacol. 2008;65:437–439.
26. Li‐Wan‐Po A, Girard T, Farndon P, Cooley C, Lithgow J. Pharmaco-
genetics of CYP2C19: functional and clinical implications of a new
variant CYP2C19 17. Br J Clin Pharmacol. 2010;69:222–230.