86 [28]. It must be emphasized that most of the studies included in this meta-analysis were indeed performed at a time when clarithromycin resistance was not as high as it is now. When compared with the sequential regimen, “concomitant” administration of the same drugs provides similar results in terms of efficacy and safety. The sequential administration protocol may produce unnecessary complexity for both patients and physicians

compared with concurrent prescription of all the medications from the outset [29]. Furazolidone has been proposed as an alternative to clarithromycin as it is economic in terms of cost and resistance but Gefitinib order its use remains uncommon. An Iranian study showed that furazolidone performed as well with clarithromycin as it did with metronidazole in a bismuth-containing regimen although neither was superior to standard triple therapy in this cohort [30]. Probiotics have been proposed as a useful adjunct for H. pylori eradication therapy by increasing tolerability, by decreasing side effects and therefore improving compliance. The benefit of such a strategy with regard to increasing eradication

has been mixed. A reasonable amount of evidence now exists to suggest that supplementation of standard triple therapy with Saccharomyces boulardii is a useful adjunct. In a cohort of patients in Korea who received S. boulardii for 4 weeks during and after a 1-week course of standard triple therapy, VEGFR inhibitor eradication rates were 10% better than for those who did not receive the supplement

[31]. A meta-analysis recently published illustrated that supplementation with S. boulardii significantly increased the eradication rate and reduced the risk of overall H. pylori therapy-related adverse effects especially diarrhea [32]. The effect of other probiotics is less well described. A study on Lactobacillus acidophilus revealed no real difference in eradication rates in patients with strains susceptible to both antibiotics, treated for peptic ulcer disease with standard triple therapy [33]. Similarly, a study on Bifidobacterium-containing yoghurt given Bacterial neuraminidase with triple therapy failed to yield any increase in eradication although rates of non-diarrhea digestive side effects such as constipation and stomatitis were reduced [34]. A number of other adjuncts apart from probiotics have also been studied in the last year. One such adjunct is the powerful mucolytic agent erdosteine. This appears to be quite an efficient adjunct, and when used alongside a 14-day triple-therapy regime in a randomized, double-blind, placebo-controlled study, it improved eradication rates from 53 to 79% on a per-protocol analysis [35]. The antiulcer drug ecabet sodium has also been studied recently on patients undergoing second-line therapy with PPI, amoxycillin, and metronidazole and did not greatly improve eradication rates [36].