It should

be noted that phenotype varies from region to region. Poor metabolizers (PM) encompass 2–4% of Caucasian and 14–20% of Asian populations, whereas extensive metabolizers make up a proportion of 18–27% in European populations but less frequently (1.3%) in Asians. There are, of course, numerous other ways in which therapy can be individualized and tailored. In an increasingly globalized world, it may be the case that different treatments are appropriate for immigrant compared with native populations, which is quite plausible given that H. pylori is a latent infection usually acquired in Erlotinib order childhood. A study from Italy this year showed statistically significant different levels of eradication in an indigenous versus immigrant population [46]. Age may also play a significant role with a recent Japanese study illustrating

that younger patients have poorer eradication Ponatinib ic50 rates and tend to have a greater incidence of side effects [47]. A particular subset of patients may need individualized management of H. pylori infection based on comorbidity. It has been illustrated that eradication levels in patients with diabetes mellitus are lower than the general population. Trials published this year looked at using newer therapeutic regimes in this group. One study that examined the use of the sequential therapy in patients with type 2 diabetes yielded disappointing results with barely over 50% of patients achieving eradication [48]. Bismuth-based therapy appears to be more promising in this cohort, though, with a per-protocol eradication rate of 51% for patients with diabetes receiving triple therapy for 14 days compared with 85% for those receiving bismuth for the same duration [49]. The literature published pertaining

to H. pylori eradication this year has shown a welcome bias toward a particular group of questions that pose challenges for clinicians. There has certainly been a greater emphasis on testing new alternatives to traditional triple therapy as first-line regimes. Still no “magic bullet” has emerged for H. pylori eradication, and the progress on a vaccine has also been frustratingly slow. Therapies based on levofloxacin and bismuth have long been reliable second-line treatments but may well be on the borderline of becoming medchemexpress the predominant first-line therapies. An advantage here may lie with the single-capsule preparation of bismuth-based therapy, which has the potential to reduce complexity and improve compliance. The value of compliance must not be understated and is the single biggest obstacle toward any eradication regime. It may also be compliance that determines whether sequential or “concomitant” regimens will be more useful. The complexity inherent in sequential therapy is considerably more than other eradication regimes, and this may limit its effectiveness. It is probably also fair to say that after a long period of uncertainty regarding probiotics, a useful role has now been established for S. boulardii as an adjunct to H.