Nonbismuth quadruple therapy, also termed “concomitant,” has been proposed as an alternative to VX-765 the sequential therapy that is less confusing for the patient and more likely to facilitate compliance with therapy. It involves using concurrently all three antibiotics with PPI usually for a period of 10–14 days. A study from

Spain showed that this performs very well in patients with clarithromycin-resistant strains, with eradication rates close to 90% [29]. Another study from Thailand reported cure rates of 96% with a 10-day concomitant therapy [30]. During this year, three trials have compared triple and concomitant therapy in Greece [11], Korea [4], and Japan [12], all of them showing an advantage of concomitant therapy (90.5 vs 73.8%, 91.4 vs 86.1%, and 94.9 vs 68.3%, respectively). Finally, two studies compared nonbismuth sequential and concomitant therapies in terms of efficacy and found comparable eradication rates with a trend toward better outcomes for concomitant therapy, with the eradication rates being

75.6 vs 80.8% and 80.0 vs 88.1%, respectively [31, 32]. An updated review on concomitant therapy, involving 2070 patients from 19 studies, confirmed a mean 88% cure rate, clearly superior to triple therapy, and with a safe profile [33]. A therapeutic Inhibitor Library cell line innovation, so-called “hybrid,” represents a combination of sequential and concomitant therapy. It consists of a standard 14-day sequential regimen but with the amoxicillin continued for the entire period, turning out to be a “concomitant” therapy for the last 7 days. In a study from Iran, hybrid therapy showed significantly superior results over sequential therapy (89.5 vs 76.7%) [23]. A study from the Nobel laureate group in Australia looked at a novel concomitant therapy with PPI, amoxicillin, rifabutin, and ciprofloxacin and obtained eradication rates of 95.2%; in cases of penicillin allergy, the amoxicillin was substituted by bismuth with no significant decrease in eradication (94.2%) [34]. Bismuth-based therapy has also been studied this year. Regarding first-line therapies, a pilot study showed an eradication

rate of 97.1% (per-protocol) for a 14-day bismuth-based quadruple classical therapy in Hispanic patients in the US [35]. Cure rates declined significantly when the duration of the therapy Calpain was 10 days or less. Another study from Turkey showed 81% cure rate on ITT analysis for a 14-day bismuth modified sequential therapy [36]. Ecabet sodium is another antiulcer drug that has been proposed as an alternative to bismuth. A study from an area of China with high levels of antibiotic resistance showed roughly equivalent eradication rates of 68.4 and 68.0% (ITT) for ecabet and bismuth-based therapy, respectively [37]. In the setting of second-line therapy, a Korean study showed eradication rates of 83.5% for 1 week and 87.7% for 2 week courses of bismuth-based therapy [38].