Aliment Pharmacol Ther 2003; 17: 1229–1236.
Meta-analysis: proton pump inhibitor or H2-receptor antagonist for
Helicobacter pylori eradication
D. Y. GR AHAM, F. H AMMOUD , H. M. T. EL-ZIMAITY , J. G. KIM , M . S. OSATO & H. B. EL-SERAG
Department of Medicine, Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
Accepted for publication 4 December 2002
SUMMARY
Aim: To compare H2-receptor antagonists and proton
pump inhibitors as adjuvants to triple therapy for
Helicobacter pylori eradication.
Methods: H. pylori-infected patients with peptic ulcer
were randomized to receive either 300 mg nizatidine or
30 mg lansoprazole plus 1 g amoxicillin and 500 mg
clarithromycin taken b.d. for 7 days. H. pylori eradica-
tion was assessed 4 weeks after therapy. Using meta-
analytical techniques, we combined the results of this
study with other randomized controlled comparisons of
H2-receptor antagonists and proton pump inhibitors as
adjuvants to triple therapy.
Results: One hundred and one patients were randomi-
zed. H. pylori eradication was 94% (47/50) [95%
confidence interval (CI), 83–99%] (intention-to-treat)
in the H2-receptor antagonist group vs. 86% (44/51)
(95% CI, 74–94%) in the proton pump inhibitor group
INTRODUCTION
Helicobacter pylori infection is aetiologically associated
with peptic ulcer disease, gastric lymphoma, chronic
gastritis and gastric adenocarcinoma.1, 2 H. pylori
eradication from the stomach has become the primary
approach for the therapy of peptic ulcer disease and
primary gastric lymphoma, and is likely to be effective
for the prevention of most cases of gastric cancer.1, 2
Correspondence to: Dr D. Y. Graham, Veterans Affairs Medical Center, RM
3A-320 (111D), 2002 Holcombe Boulevard, Houston, TX 77030, USA.
E-mail: dgraham@bcm.tmc.edu
Ó 2003 Blackwell Publishing Ltd
doi: 10.1046/j.0269-2813.2003.01583.
(P ¼ 0.3). There has been a total of 12 similar
studies (1415 patients). The overall efficacy was similar
in intention-to-treat analysis: 78% (549/701) with
H2-receptor antagonists vs. 81% (575/714) with pro-
ton pump inhibitors (odds ratio, 0.86; 95% CI, 0.66–
1.12). A non-significant trend favouring H2-receptor
antagonist (79% vs. 69%; odds ratio, 1.14; 95% CI,
0.76–1.71; P ¼ 0.5) was seen in the comparison of
clarithromycin-containing regimens. In contrast, in non-
clarithromycin-containing trials, there was a slight, but
significant, advantage with proton pump inhibitors
(85% vs. 78%; odds ratio, 0.64; 95% CI, 0.45–0.92;
P ¼ 0.02).
Conclusion: Overall, proton pump inhibitor and
H2-receptor antagonist antisecretory agents appear to
be similarly effective as adjuvants for H. pylori triple
therapy. It is unlikely that the direct anti-H. pylori effect
of proton pump inhibitors is responsible for their ability
to enhance anti-H. pylori therapy.
Successful eradication therapy requires a combination
of antimicrobial agents, typically combined with anti-
secretory agents or bismuth.3, 4
The trend has been to use proton pump inhibitors
instead of histamine-2 receptor antagonists (H2-receptor
antagonists) as antisecretory agents, in part because
proton pump inhibitors are more effective as acid
suppressants and also have antibacterial effects in vitro
and in vivo.5–10 The most commonly used antimicrobial
therapies include a combination of clarithromycin and
amoxicillin or clarithromycin and metronidazole
together with a proton pump inhibitor. The original
study showing that triple therapy with amoxicillin,
1229
1230 D. Y. GRAHAM et al.

clarithromycin and an antisecretory drug was effective METHODS

used the H2-receptor antagonist, ranitidine. The erad-
ication rate in that study was 86% [95% confidence
interval (CI), 78–99%].11 A subsequent study evaluated
clarithromycin, amoxicillin and nizatidine and reported
a cure rate of 96%, with one of the two treatment
failures having H. pylori with pre-treatment resistance
to clarithromycin.12
There have now been a number of studies showing the
effectiveness of amoxicillin and metronidazole or clarith-
romycin and metronidazole in combination with an
H2-receptor antagonist13–22 (Table 1), as well as studies
comparing triple therapy with a proton pump inhibitor
or H2-receptor antagonist23–31 (Table 2). The most
recent comparison was of a proton pump inhibitor or
H2-receptor antagonist and four antibiotics.32
The aim of this report was to present a new
randomized controlled study comparing the H2-receptor
antagonist, nizatidine, and the proton pump inhibitor,
lansoprazole, as adjuvants for H. pylori eradication
using the twice-daily combination of amoxicillin and
clarithromycin. We also performed a systematic review
of the literature, and used meta-analytical techniques to
pool the results of this study with those of several other
randomized controlled trials to compare the effective-
ness of H2-receptor antagonists and proton pump
inhibitors as adjuvants for clarithromycin-containing
triple therapy for H. pylori eradication.
Randomized controlled study
We performed a randomized controlled trial to compare
two H. pylori eradication regimens: twice-daily amoxi-
cillin and clarithromycin triple therapy using either
twice-daily nizatidine or lansoprazole as antisecretory
agent. All patients had endoscopically documented
peptic ulcers and evidence of H. pylori infection. At
endoscopy, antral and corpus mucosal biopsies were
taken and, after fixation in formalin, were sent to the
Gastrointestinal Pathology Laboratory at Baylor College
of Medicine Veterans Affairs Hospital, Houston, TX, USA
for analysis. H. pylori status was defined by histology
using a Genta triple stain. This approach has been
proven to be reliable for the confirmation of eradic-
ation.33, 34
Potential candidates eligible to participate in the study
were seen at the Korea University College of Medicine,
Seoul, South Korea. The inclusion criteria were the
presence of an active peptic ulcer, the presence of active
H. pylori infection and the willingness to participate
in the trial. Participants were randomized to receive
amoxicillin, 1 g, plus clarithromycin, 500 mg, and
either lansoprazole, 30 mg, or nizatidine, 300 mg,
twice daily for 7 days. The study was open labelled in
that the drugs were not identical. Compliance was
assessed by pill count.

Table 1. Triple therapy with a histamine-2 receptor antagonist

Antisecretory Drug 1 Drug 2 Duration No. of Cure rate Cure rate Cure rate (sensitive
Study drug (mg) (mg) (mg) (days) patients (ITT) (%) (PP) (%) strains) (%)

Breuer et al.12 N 300 at C 500 t.d.s. A 750 t.d.s. 14 72 96

bedtime
Lo et al.21 N 300 b.d. C 500 q.d.s. A 500 q.d.s. 14 25 80
Gschwantler et al.18 F 80 b.d. C 500 b.d. A 1000 b.d. 7 107 88 90
Al-Assi et al.11 R 300 at C 500 t.d.s. A 750 t.d.s. 10 29 86
bedtime
Adamek et al.17 R 300 b.d. C 500 t.d.s. M 500 t.d.s. 7 15 100
Gotz et al.15 R 300 b.d. C 500 t.d.s. M 500 t.d.s. 14 20 95
Yousfi et al.13 R 300 b.d. C 250 b.d. M 500 b.d. 14 27 78 89 (16/18)
sensitive to both
Goh et al.14 F 40 A 1000 b.d. M 500 b.d. 12 59 75 76 91
Goh et al.14 F 40 A 750 t.d.s. M 500 t.d.s. 12 65 79 83 100
Hentschel et al.19 R 300 A 750 t.d.s. M 500 t.d.s. 12 52 89
Talley et al.22 N 150 b.d. C 500 b.d. A 1000 b.d. 14 77 78 84
Talley et al.22 N 300 b.d. C 500 b.d. A 1000 b.d. 14 83 70 78

A, amoxicillin; C, clarithromycin; F, famotidine; ITT, intention-to-treat; M, metronidazole; N, nizatidine; PP, per protocol; R, ranitidine.

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 META-ANALYSIS: PPI OR H 2 -ANTAGONIST FOR H. PYLORI 1231

Table 2. Triple therapy comparing a histamine-2 receptor antagonist with a proton pump inhibitor

Antisecretory Drug 1 Drug 2 Duration No. of Cure rate Cure rate Cure rate (sensitive
Study drug (mg) (mg) (mg) (days) patients (ITT) (%) (PP) (%) strains) (%)

This study N 300 b.d. C 500 b.d. A 1000 b.d. 7 50 94 (47/50) 94 (47/50) 96
L 30 b.d. C 500 b.d. A 1000 b.d. 7 51 86 (44/51) 86 (44/51) 88
Savarino et al.24 R 300 b.d. C 250 t.d.s. A 1000 b.d. 7 80 64 (51/80) 70 (51/73)
O 20 b.d. C 250 t.d.s. A 1000 b.d. 7 80 57 (46/80) 67 (46/69)
Gschwantler et al.23 F 80 b.d. C 250 b.d. M 500 b.d. 7 60 78 (47/60) 90 (47/52) 93
O 20 b.d. C 250 b.d. M 500 b.d. 7 60 73 (44/60) 77 (44/57) 84
Lazzaroni et al.25 R 300 C 250 b.d. M 500 b.d. 14 40 85 (34/40)
L 30 C 250 b.d. M 500 b.d. 14 40 90 (36/40)
Kihira et al.16 R 300 C 200 b.d. M 250 b.d. 7 48* 91 (44/48)
L 30 C 200 b.d. M 250 b.d. 7 43 94 (40/43)
Spadaccini et al.26 R 300 b.d. C 250 b.d. T 500 b.d. 7 50 86 (43/50)
O 20 b.d. C 250 b.d. T 500 b.d. 7 50 92 (46/50)
Grigoriev et al.30 R 150 b.d. A 1000 b.d. M 500 b.d. 14 15 80 (12/15)
O 20 b.d. A 1000 b.d. M 500 b.d. 14 15 87 (13/15)
Lamouliatte et al.29 R 300 A 1000 b.d. T 500 b.d. 22 81 (18/22)
(15 days) (10 days)
O 22 A 1000 b.d. T 500 b.d. 22 86 (19/22)
(15 days) (10 days)
Ell et al.27 R 300 q.d. A 750 t.d.s. M 500 t.d.s. 7 178 77 (137/178) 76 87
O 40 q.d. A 750 t.d.s. M 500 t.d.s. 7 194 87 (169/194) 87 95
Tham et al.31 R 600 b.d. A 500 t.d.s. M 400 t.d.s. 14 18 44 (8/18) 100
O 20 b.d. A 500 t.d.s. M 400 t.d.s. 14 19 32 (6/19) 71
Savarino et al.24 R 300 b.d. A 1000 b.d. M 500 b.d. 7 80 75 (60/80) 85 (60/71)
O 20 b.d. A 1000 b.d. M 500 b.d. 7 80 77 (62/80) 89 (62/70)
Hsu et al.28 F 40 b.d. A 1000 b.d. T 500 b.d. 14 60 80 (48/60) 91 (48/53) 91
O 20 b.d. A 1000 b.d. T 500 b.d. 14 60 83 (50/60) 88 (50/57) 92

A, amoxicillin; C, clarithromycin; F, famotidine; ITT, intention-to-treat; L, lansoprazole; M, metronidazole; N, nizatidine; O, omeprazole; PP, per
protocol; R, ranitidine; T, tinidazole.
* Patients without previous Helicobacter pylori therapy.

Outcomes were assessed at least 4 weeks after the end

of treatment by repeat endoscopy with gastric biopsy for
histology. Some patients underwent repeat testing when
they presented later with recurrent symptoms (not later
than 6 months). The primary outcome was eradication
of H. pylori defined by negative histology for the antrum
and corpus. A single pathologist, who was blind to the
nature of the study, examined the histological slides
prepared from the gastric mucosal biopsies. The secon-
dary outcome was healing of the ulcer(s) as assessed by
repeat endoscopy.
The two treatment groups were compared with respect
to demographic features and baseline disease characteri-
stics. In an intention-to-treat analysis, the proportions of
patients achieving primary or secondary outcomes were
compared between the two treatment groups. For all
comparisons, v2 tests were used for dichotomous
variables and t-tests for continuous variables.
Systematic review of the literature/meta-analysis
We performed a systematic review of the literature to
identify therapeutic trials comparing the efficacy of
H. pylori therapy between H2-receptor antagonists and
proton pump inhibitors used in triple therapy combina-
tions. Medline and Embase searches were carried out
between 1990 and 2001. The bibliographies of the
articles were also searched for relevant papers or
abstracts. Only randomized controlled studies that
reported an intention-to-treat analysis or row numbers
that allowed for the calculation of an intention-to-treat
analysis were selected. Both abstracts and full articles
were included. Two independent investigators abstrac-
ted the relevant data (DYG, FH). Subsequently, the
results of the current study were pooled with those of
the studies identified in the systematic review that
satisfied our inclusion criteria. In addition to pooling the

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1232 D. Y. GRAHAM et al.

results of all studies that satisfied our criteria, we
decided a priori to examine the pooled results from: (i)
studies containing clarithromycin in both treatment
groups; (ii) studies containing no clarithromycin in
either treatment group; (iii) studies with a treatment
duration of 1 week; and (iv) studies with a treatment
duration of 2 weeks.
A random (DerSimonian–Laird) model assumption
was used in the meta-analysis.35 Tests of homogeneity
were performed for all studies, as well as for the
subgroups defined above. The results of the meta-
analysis were expressed as pooled odds ratios (ORs) for
the eradication of H. pylori using H2-receptor antago-
nists compared with proton pump inhibitors, and their
accompanying 95% CIs.
RESULTS
Randomized controlled study
One hundred and one patients were randomized,
including 50 in the nizatidine group and 51 in the
lansoprazole group. The nizatidine group consisted of
45 men and five women between 24 and 80 years of
age (median, 52 years), and the lansoprazole group
consisted of 36 men and 15 women between 22 and
76 years of age (median, 49 years). There were no
differences in the demographic characteristics (Table 3).
All patients had active H. pylori infection by histology
and had at least one ulcer in the stomach, duodenum or
both. All randomized patients completed the study and
there was a 100% follow-up. The combinations were
well tolerated and adherence was > 95%.
H. pylori eradication was achieved in 47 of 50 (94%)
(95% CI, 83–99%) patients in the nizatidine group
compared with 44 of 51 (86%) (95% CI, 74–94%)
patients in the lansoprazole group (P ¼ 0.33). The 95%
CI for the difference in proportions overlapped zero
() 21% to + 5%).
One of the seven patients who failed treatment in the
lansoprazole group had negative histology at the initial
post-therapy evaluation, but H. pylori was detected at a
4-month follow-up visit. Although it is not known
whether this finding represented re-infection or recru-
descence, the case was scored as a failure. Inclusion of
this case as a success would not change the outcome
significantly.
Pre-treatment cultures were available for eight of the
nine patients who failed therapy in both groups, and
clarithromycin resistance was present in only one
patient in the nizatidine group and one in the lanso-
prazole group. All ulcers were healed in 42 (84%)
patients in the nizatidine group compared with 49
(96%) in the lansoprazole group (P ¼ 0.09).
Meta-analysis
In the systematic review, we identified 11 studies
(including the present study) containing 12 relevant
comparisons that satisfied our criteria; these studies
were included in a meta-analysis. All studies were
randomized, controlled and with intention-to-treat
analyses. The number of patients included in each
treatment arm ranged from 15 to 194, the duration of
therapy from 7 to 14 days and the H. pylori eradication
rate from 75% to 94%. The overall eradication rate with

Table 3. Baseline characteristics of the

Lansoprazole group Nizatidine group
study patients
Number of patients 51 50
Men 36 (71%) 45 (90%)
Age (years) 22–76 (median, 49) 24–80 (median, 52)
H. pylori at follow-up visits 44 cured (86%) 47 cured (94%)
7 failed (14%) 3 failed (6%)
Smoking 28 31
26 from cured group 30 from cured group
2 from failed group 1 from failed group
Ulcer(s) healed at follow-up visits 49 47
42 from cured group 45 from cured group
7 from failed group 2 from failed group
Ulcer(s) not healed 1 from cured group 3
at follow-up visits 2 from cured group
1 from failed group
Unknown ulcer healing 1 from cured group None

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 META-ANALYSIS: PPI OR H 2 -ANTAGONIST FOR H. PYLORI 1233

H2RA PPI OR OR
Study 95%CI Random) 95%CI Random)
29 12/15 13/15 0.62[0.09,4.34]
25 31/37 23/26 0.67[0.15,2.98]
28 18/22 19/22 0.71[0.14,3.63]
26 137/178 169/194 0.49[0.29,0.85]
27 48/60 50/60 0.80[0.32,2.02]
this study 47/50 44/51 2.49[0.61,10.25]
16 44/48 40/43 0.82[0.17,3.91]
23 51/80 46/80 1.30[0.69,2.45]
Figure 1. A Peto graph showing the indi- 22 47/60 44/60 1.31[0.57,3.04]
24 34/ 40 36/ 40 0.63[0.16,2.43]
vidual study’s odds ratios (ORs) and the 25 43/50 46/50 0.53[0.15,1.95]
23 60/80 62/80 0.87[0.42,1.81]
pooled OR for all studies comparing suc-
cessful Helicobacter pylori eradication Total(95%CI) 572/720 592/721 0.83[0.63,1.09]
Test for heterogeneity chi-square=9.68 df=11 P =0.56
between combinations that contained
histamine-2 receptor antagonist (H2RA) 0.1 0.2 1 5 10
vs. proton pump inhibitor (PPI). Favours treatment Favours control

H2-receptor antagonist-containing combinations was
549 of 701 (78%) patients, whereas that of proton
pump inhibitor-containing combinations was 575 of
714 (81%) patients. Only the results of intention-to-
treat analyses were pooled. Where reported, the dropout
rates were low (< 11%); two studies were published in
abstract form only.29, 30
Tests of homogeneity were negative for all calculations
(P > 0.05), indicating that there were no significant
differences in the results of the individual studies and
thus that it was appropriate to pool the results. When
all 12 comparisons were combined in the random model
(i.e. more conservative), the pooled OR for the eradica-
tion of H. pylori using H2-receptor antagonists compared
with proton pump inhibitors was 0.86 (95% CI, 0.66–
1.12; P ¼ 0.3) (Figure 1). In other words, combinations
containing proton pump inhibitors were 14% more
likely to cause H. pylori eradication than those contain-
ing H2-receptor antagonists; this was not statistically
significantly different.
There were no significant differences in the rates of
H. pylori eradication between the combinations con-
taining H2-receptor antagonists or proton pump inhib-
itors when pooling the results of 1-week studies (seven
studies; pooled OR, 0.86; 95% CI, 0.64–1.17) and
2-week studies (three studies; pooled OR, 0.96; 95% CI,
0.48–1.94). There was a non-significant trend favour-
ing H2-receptor antagonists (69% vs. 79%; six studies;
OR, 1.14; 95% CI, 0.76–1.71; P ¼ 0.5) when clarithro-
mycin-containing regimens were compared. Conversely,
the pooled OR from studies not using clarithromycin in
either treatment group revealed a small but significant
benefit in H. pylori eradication favouring proton pump
inhibitor-containing regimens (six studies; OR, 0.64;
95% CI, 0.45–0.92; P ¼ 0.02). The overall eradication
rate was 306 of 392 (78%; 95% CI, 74–82%) in studies
with H2-receptor antagonist-containing combinations
vs. 336 of 397 (85%; 95% CI, 80.7–88%) in studies
using proton pump inhibitors.
DISCUSSION
The efficacy of both clarithromycin and amoxicillin as
antimicrobials is enhanced by antisecretory drug ther-
apy. Proton pump inhibitors not only directly block the
proton pump on parietal cells in the stomach, but also
have antibacterial activity against H. pylori both in vivo
and in vitro. In contrast, H2-receptor antagonists have
no intrinsic antibacterial activity. This randomized
study, as well as the meta-analysis, showed that H. pylori
eradication triple therapy using twice-daily amoxicillin
and clarithromycin was similarly effective independent
of whether the antisecretory agent was a proton pump
inhibitor or an H2-receptor antagonist. This conclusion
is consistent with the notion that the adjuvant effect
with antisecretory therapy is related more to the drugs’
ability to suppress acid secretion than to its antibacterial
activity.
Most studies of H. pylori eradication using triple
therapy have used proton pump inhibitors as the
antisecretory component. Many of the large controlled
trials were performed to obtain approval for different
antimicrobial therapies for the treatment of H. pylori
infection, and were sponsored by pharmaceutical com-
panies manufacturing proton pump inhibitors. Thus,
the majority of studies of amoxicillin and clarithromycin
or metronidazole and clarithromycin have used a pro-
ton pump inhibitor. One rationale for this choice was
that proton pump inhibitor antisecretory therapy had
been shown to be superior to H2-receptor antagonists in

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1234 D. Y. GRAHAM et al.
ulcer healing, pH control and the rapidity of pain relief.
All of these benefits were likely to be present when
proton pump inhibitors were used as part of the therapy
of H. pylori infection in patients with peptic ulcer
disease.
Most of the studies in which a proton pump inhibitor and
H2-receptor antagonist have been compared have shown
no significant difference in the eradication of H. pylori.
High eradication rates have been reported with both
antisecretory agents. Given the lack of statistically
significant heterogeneity between the results of the
studies examined, pooling the results in a meta-analytical
approach was appropriate. The results of the meta-
analysis confirm the lack of significant differences in the
rate of H. pylori eradication between studies with
proton pump inhibitors or H2-receptor antagonists. These
results are consistent with those of a previous analysis
that examined fewer studies.36 However, when the
results of studies that contained or did not contain
clarithromycin were pooled, there was a slight, but
significant, advantage of proton pump inhibitor-contain-
ing combinations in non-clarithromycin-containing reg-
imens. The reason for this difference is unclear and
deserves further study. One possibility is related to the fact
that clarithromycin is more dependent than metroni-
dazole on pH control. The elimination or reduction of
H. pylori in the stomach eliminates the ammonia
produced by the action of H. pylori urease and, at least
in the short term, H2-receptor antagonists are more
effective in controlling nocturnal pH than are proton
pump inhibitors.
Antibiotic-related factors may be at least as important
as the choice of antisecretory agent in determining the
overall efficacy of H. pylori eradication therapy. For
example, antimicrobial resistance is a major cause of
treatment failure, and current data suggest that clarith-
romycin resistance cannot be overcome by increasing
the clarithromycin dosage or the duration of ther-
apy.37, 38 Some data suggest that increasing the dose
of antibiotic administered may achieve better results.
For example, in the study by Adamek et al., higher doses
of clarithromycin (500 mg b.d.) and metronidazole
(500 mg t.d.s.) were used, and a 100% cure rate was
achieved; that study also used a higher dose of
ranitidine (300 mg b.d.).17 Detailed comparisons of
the different combinations and permutations are gen-
erally lacking, and thus it is difficult to draw unassail-
able conclusions regarding drug combinations for
H. pylori eradication.
Ó 2003 Blackwell Publishing Ltd, Aliment Pharmacol Ther 17, 1229–1236
In conclusion, 1 week of treatment with either an
H2-receptor antagonist or a proton pump inhibitor,
together with amoxicillin and clarithromycin, was
similarly effective in the eradication of H. pylori and in
the healing of peptic ulcers. As the outcomes of
H2-receptor antagonist and proton pump inhibitor triple
therapy are similar, and both are well tolerated by
patients, one might use cost to choose between them.
Generally, H2-receptor antagonists cost less than proton
pump inhibitors, which favours their use, especially in
developing countries.
ACKNOWLEDGEMENTS
This work was supported in part by the Office of
Research and Development Medical Research Service
Department of Veterans Affairs and by Public Health
Service grant DK56338 which funds the Texas Gulf
Coast Digestive Diseases Center. Dr El-Serag is the
recipient of a Veterans Affairs Health Services Research
and Development (HSR&D) Research Development
Award (RCD 00-013-2).
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