Comparing the Efficacy and Impact on Gastrointestinal Microbiota of Reverse Hybrid Therapy and Concomitant Therapy in Helicobacter Pylori Eradication
Phase: NA
Conditions: Helicobacter Pylori Infection
Sponsor: Kaohsiung Veterans General Hospital.

 
1 
 
VGHKS15-CT7-15 
Institution/Department：Kaohsiung Veterans General Hospital 
Principal Investigator (PI)：Prof. Ping-I Hsu  
Research Project Title：Comparing the Efficacy of Reverse Hybrid Therapy and 
Concomitant Therapy 
NCT Number：NCT02646332  
Date of the document：   8   31   2020  （MM/DD/YYYY）  
 
 
ABSTRACT 
Background: With the rising prevalence of antimicrobial resistance, the failure rate of the standard 
triple therapy has declined to unacceptable level (<80%) worldwide. A 14-day hybrid therapy 
invented by our study group appears very promising in H pylori eradication, achieving excellent 
eradication rates of 99% and 97% according to per-protocol and intention-to-treat analyses, 
respectively. Recently, we reversed the drug administration sequence of hybrid therapy and 
developed a new two-phase one-step treatment — reverse hybrid therapy. The new therapy is 
superior to standard triple therapy for H pylori eradication, but whether it also achieves a high 
eradication rate than sequential or concomitant therapy remains unanswered. Additionally, the 
impacts of reverse hybrid therapy and aforementioned new therapies on gastrointestinal microbiota 
are unclear. 
Aims: The aims of this randomized controlled trial are (1) to compare the efficacies of reverse 
hybrid therapy and concomitant therapy, (2) to investigate the host and bacterial factors predicting 
the treatment outcomes of the two eradication regimens. 
Methods: Consecutive 248 H. pylori-infected subjects are randomly assigned to receive either a 
14-day reverse hybrid therapy or a 14-day concomitant therapy. On recruitment, blood sampling for 
genotyping of CYP2C19 is carried out, and antibiotic susceptibility of H pylori strains will be 
checked. Subjects are asked to return at the end of the 2nd week to assess drug compliance and 

 
2 
 
VGHKS15-CT7-15 
adverse events. H pylori status will be re-assessed at week 6 after the end of anti- H. pylori therapy. 
Finally, the rates of eradication, adverse events and compliance will be compared between groups 
by chi-square test, and the host and bacterial factors influencing each efficacy of the regimen are 
assessed by multivariate analysis.  
 
Introduction 
Helicobacter pylori (H. pylori) infect more than 50% of humans globally. It is the 
principal cause of chronic gastritis, gastric ulcer, duodenal ulcer, gastric adenocarcinoma and 
gastric mucosa-associated lymphoid tissue lymphoma (MALToma) [1,2]. In most international 
guidelines [3-6], standard triple therapy consisting of a proton-pump inhibitor (PPI), 
clarithromycin and amoxicillin (or metronidazole) for 7 to 14 days is recommended as the 
choice of treatment for first-line therapy of H pylori infection, especially in areas of low 
clarithromycin resistance (< 15%). Recently, the eradication rates of standard triple therapy 
have declined to less than 80% in many countries, largely owing to emerging organism 
resistances [7-10].  Some European studies even reported very poor treatment outcomes of the 
standard therapy with failure rates of 25-60% [11-13]. Several strategies including sequential 
therapy, concomitant therapy and hybrid therapy have therefore been proposed to increase the 
eradication rate [14-16]. 
   Concomitant therapy is another novel regimen proven successful in the presence of 
clarithromycin resistance [15]. It is a 4-drug regimen containing a PPI (standard dose, b.i.d.), 
clarithromycin (500 mg, b.i.d.), amoxicillin (1 g, b.i.d.) and metronidazole (500 mg, b.i.d.) 

 
3 
 
VGHKS15-CT7-15 
which are all given for the entire duration of therapy. This therapy is superior to standard triple 
therapy for H pylori eradication [17]. It is also less complex than sequential therapy as this 
regimen does not involve changing drugs halfway through. A head-to-head non-inferiority trial 
of 10-day sequential and 10-day concomitant therapy showed they were equivalent (93.1% vs 
93.0% by per-protocol analysis) [18]. 
   Recently, we have developed a new anti-H pylori regimen — hybrid therapy , which 
consists of a dual therapy with a PPI (standard dose, b.i.d.) and amoxicillin (1 g, b.i.d.) for 7 
days followed by a quadruple regimen with a PPI (standard dose, b.i.d.), amoxicillin (1 g, 
b.i.d.), clarithromcyin (500 mg, b.i.d.) and metronidazole (500 mg, b.i.d.) for 7 days [16]. The 
novel therapy provided excellent eradication rates of 99% and 97% according to per-protocol 
and intention-to-treat analysis [16]. Several randomized controlled trials subsequently 
demonstrated that hybrid regimens were comparable with or more effective than sequential 
regimens [19-22]. It is important to note that the new therapy has a high efficacy in the 
treatment of H pylori strains harboring dual resistance to clarithromycin and metronidazole. 
Several studies have shown that sequential therapy is ineffective to clear H pylori with dual 
resistance [14]. The prolonging treatment duration of amoxicillin to 14 days in hybrid therapy 
might account for the higher eradication rate in the face of H pylori stains with dual resistance 
to clarithromycin and metronidazole. A study from Italy [20] which compared markedly 
different durations of therapy (14-day hybrid therapy vs 5-day concomitant therapy) showed 
that 14-day hybrid therapy was superior by PP analysis (95.7% vs 85.1%). However, another 

 
4 
 
VGHKS15-CT7-15 
randomized controlled trial showed comparable eradication efficacy between hybrid and 
concomitant therapies [23].  The study also showed that there was a borderline significant 
trend toward higher compliance with hybrid therapy compared with concomitant therapy (99% 
vs 95%) [23]. Many expert recommendations therefore proposed hybrid therapy as a treatment 
option for H pylori in areas with moderate or high clarithromycin resistance [24-27]. 
Switching drugs halfway through the course increases the complexity of an anti-H pylori 
regimen. Reversing the sequence of drug administration (a quadruple regimen followed by a dual 
regimen) simplifies hybrid therapy and make it become a one-step two-phase therapy. We recently 
conducted a  multi-center, randomized controlled trial to compare the efficacies of reverse hybrid 
therapy and standard triple therapy [28]. The data indicated that reverse hybrid therapy achieved a 
higher eradication rate than standard triple therapy (95.5% vs 88.6%) by ITT analysis. 
Currently, whether reverse hybrid therapy is superior to concomitant therapy in H pylori 
eradication remains unanswered. Theoretically, the ideal treatment for H pylori infection should be 
a cheap, highly effective, and well-tolerated therapy. Since the pharmaceutical cost of 14-day 
reverse hybrid therapy is cheaper than 14-day concomitant therapy, the former would be a better 
choice than the latter for H pylori eradication if its eradication rate is superior or non-inferior to that 
of concomitant therapy.We hence conduct the randomized controlled trial are (1) to compare the 
efficacies of 14-day reverse hybrid therapy and 14-day concomitant therapy, (2) to investigate the 
host and bacterial factors predicting the treatment outcomes of the two eradication regimens. 
 

 
5 
 
VGHKS15-CT7-15 
PATIENTS & METHODS 
Study population 
   The open-labeled trial is conducted at the Kaohsiung Veterans General Hospital and Kaohsiung 
Medical University Hospital in Taiwan in accordance with the principles of good clinical practice 
from the Declaration of Helsinki. The study protocol will be approved by the Ethics Committees 
of the Kaohsiung Veterans General Hospital and the Kaohsiung Medical University Hospital. All 
patients give written informed consent before participating in the study. 
   We will recruit 248 patients to the study if they meet the following criteria: they are adult 
patients aged  20 years and have H pylori infection. The exclusion criteria include The exclusion 
criteria include (1) previous H pylori-eradication therapy, (2) patient with allergic history to the 
medications used,  (3) patients with previous gastric surgery, (4) coexistence of serious 
concomitant illness (for example, decompensated liver cirrhosis, uremia), and (5) pregnant 
women. 
 
Randomization and treatment 
This is a randomized controlled trial. Eligible H. pylori-infected subjects are randomly 
assigned to a 14-day reverse hybrid therapy (a 7-day quadruple regimen with dexlansoprazole MR 
60 mg once daily, amoxicillin 1 g twice daily, clarithromycin 500 mg twice daily, and 
metronidazole 500 mg twice daily, followed by a 7-day dual regimen with dexlansoprazole MR 60 
mg once daily and amoxicillin 1 g twice daily) or a 14-day concomitant therapy (dexlansoprazole 

 
6 
 
VGHKS15-CT7-15 
MR 60 mg once daily, amoxicillin 1 g twice daily, clarithromycin 500 mg twice daily, and 
metronidazole 500 mg twice daily for 14 days). All drugs are taken one hour before breakfast or 
dinner. Patients with peptic ulcers in initial endoscopy receive an additional 4-week 
dexlansoprazole MR therapy (60 mg orally once daily), while patients with symptomatic gastritis 
only take additional four-weeks of antacid.  
On recruitment, patients are requested to complete a standard record for a complete medical 
history and demographic data. Additionally, blood sampling for genotyping of CYP2C19 is carried 
out. To assess eradication efficacy and status of ulcer healing, repeated endoscopy with rapid urease 
test, histological examination and culture is performed for peptic ulcer patients at the sixth week 
after the end of anti- H. pylori therapy. Urea breath test is conducted to assess H. pylori status in the 
subjects with gastritis and in peptic ulcer subjects who refuse follow-up endoscopy,. Eradication is 
defined as (1) negative results of both rapid urease test and histology, or (2) a negative result of urea 
breath test.     
Finally, the eradication rates by both intention-to-treat and per-protocol analyses, adverse 
events and compliance will be compared between groups by chi-square test, and the host and 
bacterial factors influencing the efficacy of eradication therapy are assessed by multivariate 
analysis. 
 
Statistical analysis 
The primary outcome variable is eradication rate. The secondary outcome variables are the rate 

 
7 
 
VGHKS15-CT7-15 
of adverse events and compliance. Chi-square test with or without Yates correction for continuity 
and Fisher’s exact test are used when appropriate to compare the major outcomes between groups 
using the SPSS program (version 10.1, Chicago, Illinois, USA). A P value less than 0.05 is 
considered statistically significant.  
    Eradication rates are evaluated by ITT and per-protocol (PP) analyses. ITT analysis includes 
all randomized patients who have taken at least one dose of study medication. Patients whose 
infection status is unknown following treatment are considered treatment failures for the purposes 
of ITT analysis. The PP analysis excludes the patients with unknown H. pylori status following 
therapy and those with major protocol violations.  
    To determine the independent factors affecting the treatment response, Host and bacterial 
parameters are analyzed by univariate analysis. These variables include the following: age (<60 or 
60 years), gender, history of smoking, history of alcohol consumption (<80 g/day or 80 g/day), 
ingestion of coffee (<1 cup/day or 1 cup/day), ingestion of tea ((<1 cup/day or 1 cup/day), 
coexistence of a systemic disease (yes or no), previous history of peptic ulcer disease, endoscopic 
appearance (ulcer or gastritis), CYP2C19 polymorphism, drug compliance (good or poor), and 
antibiotic susceptibility. Those variables found to be significant by univariate analysis are 
subsequently assessed by a stepwise logistic regression method to identify independent factors for 
eradication outcome. 
 
REFERENCES 
1.  Vakil N, Megraud E. Eradication treatment for Helicobacter pylori. Gastroenterology 
2007:133:985-1001. 
2.  Hunt RH, Lam SK. Helicobacter pylori: from art to a science. J Gastroenterol Hepatol 
1998;13:21-8. 

 
8 
 
VGHKS15-CT7-15 
3.  Fock KM, Katelaris P, Sugano K, et al. Second Asia-Pacific Consensus Guidelines for 
Helicobacter pylori infection. J Gastroenterol Hepatol 2009;24:1587-600. 
4.  Asaka M, Kato M, Takahashi S, et al, Guidelines for the management of Helicobacter 
pylori infection in Japan: 2009 revised edition. Helicobacter 2010;15:1–20. 
5.  Malfertheiner P, Megraud F, O’Morain CA, et al. Management of Helicobacter pylori 
infection — The Maastricht IV/ Florence Consensus Report. Gut 2012;61:646-64. 
6.  Chey WD, Wong BCY. American College of Gastroenterology guideline on the 
management of Helicobacter pylori infection. Am J Gastroenterol 2007;102:1808–25. 
7.  Graham DY, Akiko S. New concepts of resistance in the treatment of Helicobacter pylori 
infections. Nature Clin Pract Gastroenterol Hepatol 2008;5:321-31. 
8.  Megraud F. H pylori antibiotic resistance: prevalence, importance, and advances in testing. 
Gut 2004; 53:1374–84. 
9.  Luther J, Higgins PD, Schoenfeld PS, et al. Empiric quadruple vs triple therapy for 
primary treatment of Helicobacter pylori infection: systematic review and meta-analysis 
of efficacy and tolerability. Am J Gastroenterol 2010;105:65–73. 
10.  De Francesco V, Margiotta M, Zullo A, et al. Clarithromycin-resistant genotypes and 
eradication of Helicobacter pylori. Ann Intern Med 2006;144:94–100. 
11.  Gumurdulu Y, Serin E, Ozer B, et al. Low eradication rate of Helicobacter pylori with 
triple 7-14 days and quadruple therapy in Turkey. World J Gastroenterol 2004;10:668-71.  
12.  Bigard MA, Delchier JC, Riachi G, et al. One-week triple therapy using omeprazole, 

 
9 
 
VGHKS15-CT7-15 
amoxycillin and clarithromycin for the eradication of Helicobacter pylori in patients with 
non-ulcer dyspepsia: influence of dosage of omeprazole and clarithromycin. Aliment 
Pharmacol Ther 1998;12:383-8. 
13.  De Francesco V, Margiotta M, Zullo A, et al. Prevalence of primary clarithromycin 
resistance in Helicobacter pylori strains over a 15 year period in Italy. J Antimicrob 
Chemother 2007;59:783–5. 
14.  Zullo A, De Francesco V, Hassan C, et al. The sequential therapy regimen for 
Helicobacter pylori eradication: a pooled-data analysis. Gut 2007;56:1353–7. 
15.  Essa AS, Kramer JR, Graham DY, et al. Meta-analysis: four-drug, three-antibiotic, 
non-bismuth-containing “concomitant therapy” versus triple therapy for Helicobacter 
pylori eradication. Helicobacter 2009;14:109–18. 
16.  Hsu PI, Wu DC, Wu JY, et al. Modified sequential Helicobacter pylori therapy: proton 
pump inhibitor and amoxicillin for 14 days with clarithromycin and metronidazole added 
as a quadruple (hybrid) therapy for the final 7 days. Helicobacter 2011;16:139-45. 
17.  Essa AS, Kramer JR, Graham DY, Treiber G. Meta-analysis: four-drug, three-antibiotic, 
non-bismuth-containing "concomitant therapy" versus triple therapy for Helicobacter 
pylori eradication. Helicobacter 2009; 14: 109-118.  
18.  Wu DC, Hsu PI, Wu JY, Opekun AR, Kuo CH, Wu IC, Wang SS, Chen A, Hung WC, 
Graham DY. Sequential and concomitant therapy with 4 drugs are equally effective for 
eradication of H. pylori Infection. Clin Gastroenterol Hepatol 2010; 8: 36-41.   

 
10 
 
VGHKS15-CT7-15 
19.  Sardarian H, Fakheri H, Hosseini V, et al. Comparison of Hybrid and Sequential Therapies 
for Helicobacter pylori Eradication in Iran: A Prospective Randomized Trial. Helicobacter 
2013;18:129-34. 
20.  De Francesco V, Hassan C, Ridola L, et al. Sequential, concomitant and hybrid first-line 
therapies for Helicobacter pylori eradication: a prospective randomized study. J Med 
Microbiol. 2014;63:748-52. 
21.  Oh DH, Lee DH, Kang KK, et al. The efficacy of hybrid therapy as first-line regimen for 
Helicobacter pylori infection compared with sequential therapy. J Gastroenterol Hepatol 
2014;29:1171-6. 
22.  Wang B, Wang YH, Lv ZF, et al. Efficacy and safety of Hybrid therapy for Helicobacter 
pylori infection: a systemic review and meta-analysis. 2014;doi: 10.1111/hel.12180. 
23.  Molina-Infante J, Romano M, Fernandez-Bermejo M, et al. Optimized nonbismuth 
quadruple therapies cure most patients with Helicobacter pylori infection in populations 
with high rates of antibiotic resistance. Gastroenterology. 2013;145:121-8. 
24.  Chuah SK, Tsay FW, Hsu PI, et al. A new look at anti-Helicobacter pylori therapy. World J 
Gastroenterol 2011;17:3971-5. 
25.  Georgopoulos SD, PapastergiouV, Karatapanis S. Helicobacter  pylori eradication 
therapies in the era of increasing antibiotic resistance: a paradigm shift to improved 
efficacy. Gastroenterol Res Pract 2012;757926. 
26.  Rimbara E, Fischbach LA, Graham DY. Optimal therapy for Helicobacter pylori 

 
11 
 
VGHKS15-CT7-15 
infections. Nat Rev Gastroenterol Hepatol 2011;8:79–88. 
27.  Hsu PI, Kao SS. Therapy of Helicobacter pylori Infection: Many Drugs for Which 
Association? In: Helicobacter pylori. 347-362 Editors: Marco Manfredi and Gian Luigi 
de'Angelis. Nova Science Publishers, Inc. New York (2013). 
28.  Hsu PI, Wu DC, Tsay, FW. Reverse hybrid therapy versus standard triple therapy for 
Helicobacter pylori infection — A multi-center, randomized, controlled trial. 
Gastroenterology 2014;146(Suppl 1):S740.