Ranitidine bismuth citrate-based triple therapies after failure of the standard 'Maastricht triple therapy': A promising alternative to the quadruple therapy?

Background: Triple therapy with proton pump inhibitor, clarythromycin, and amoxicillin has been proposed in Maastricht as the first-line treatment of H. pylori infection. Aim: To determine whether ranitidine bismuth citrate (RBC) based regimens may be used as second-line treatments after 'Maastricht therapy' failure. Methods: A total of 285 patients with H. pylori infection were given a 7-day treatment with pantoprazole 40 mg b.d., clarythromycin 500 mg b.d., and amoxicillin 1 g b.d. Patients who were still infected were randomly given one of the following 14-day treatments: RBC 400 mg b.d. plus amoxicillin 1 g b.d. and tinidazole 500 mg b.d. (RAT group), RBC 400 mg b.d. plus amoxicillin 1 g b.d. and clarythromycin 500 mg b.d. (RAC group), and RBC 400 mg b.d. plus clarythromycin 500 mg b.d. and tinidazole 500 mg b.d. (RCT group). Results: The 'Maastricht therapy' achieved an eradication rate of 59% (95% CI: 54-65) on intention-to-treat analysis. The RAT, RAC, and RCT regimens achieved eradication rates of 81% (95% CI: 67-94), 43% (95% CI: 26-60), and 62% (95% CI: 44-80), respectively, on intention-to-treat analysis. Patient compliance was optimal in RAT and RAC groups. Conclusion: RBC plus tinidazole and either amoxicillin or clarythromycin can be used as second-line therapies after failure of the Maastricht triple therapy.