potent and longer acting acid suppressants, namely potassium-com-
petitive acid blockers (P-CABs), may represent a step forward.
showed that vonoprazan-based triple therapy
had superior efficacy compared to PPI-based triple therapy, with
comparable tolerability and incidence of adverse events. However,
all the studies were performed in Japan. If P-CAB-based therapies
perform similarly in other regions, vonoprazan could represent a real
breakthrough, and might even make the dream of a dual therapy
The authors’ declarations of personal and financial interests are
unchanged from those in the original article.
This article is linked to Gatta et al and Siddique and Moss papers. To
view these articles visit https://doi.org/10.1111/apt.14597 and
Clinical Pharmacology & Digestive Pathophysiology Unit, Department of
Clinical & Experimental Medicine, University of Parma, Parma, Italy
1. Siddique O, Moss SF. Editorial: Helicobacter pylori resistance and
sequential therapy. Aliment Pharmacol Ther. 2018;48:95-96.
2. Marshall BJ, Warren JR. Unidentified curved bacilli in the stomach of
patients with gastritis and peptic ulceration. Lancet. 1984;1:1311-1315.
3. Graham DY, Dore MP. Helicobacter pylori therapy: a paradigm shift.
Expert Rev Anti Infect Ther. 2016;14:577-585.
4. Thung I, Aramin H, Vavinskaya V, et al. Review article: the global
emergence of Helicobacter pylori antibiotic resistance. Aliment Phar-
macol Ther. 2016;43:514-533.
5. Gatta L, Scarpignato C, Fiorini G, et al. Impact of primary antibiotic
resistance on the effectiveness of sequential therapy for Helicobacter
pylori infection: lessons from a 5-year study on a large number of
strains. Aliment Pharmacol Ther 2018;47:1261-1269.
6. Malfertheiner P, Megraud F, O’Morain CA, et al. Management of
Helicobacter pylori infection-the Maastricht V/florence consensus
report. Gut. 2017;66:6-30.
7. Scarpignato C, Gatta L, Zullo A, et al. Effective and safe proton
pump inhibitor therapy in acid-related diseases – a position paper
addressing benefits and potential harms of acid suppression. BMC
8. Yang JC, Lin CJ, Wang HL, et al. High-dose dual therapy is superior
to standard first-line or rescue therapy for Helicobacter pylori infec-
tion. Clin Gastroenterol Hepatol. 2015; 13: 895-905.e5.
9. Scarpignato C, Hunt RH. Editorial: towards extended acid suppression–
the search continues. Aliment Pharmacol Ther. 2015;42:1027-1029.
10. Jung YS, Kim EH, Park CH. Systematic review with meta-analysis:
the efficacy of vonoprazan-based triple therapy on Helicobacter
pylori eradication. Aliment Pharmacol Ther. 2017;46:106-114.
Editorial: an argument for low-dose thiopurine allopurinol
combination use as first-line therapy in inflammatory bowel
We would like to congratulate Dr Friedman and colleagues for their
randomised clinical trial on the efficacy, safety and dosage of adjunc-
tive allopurinol in azathioprine/mercaptopurine nonresponders with
inflammatory bowel disease (IBD).
It is refreshing to read studies
reporting on the optimisation and repurposing of “old small mole-
cules” in IBD.
In our view, the central message from this study is that the com-
bination of allopurinol with low-dose thiopurine is safe and effective
for inducing remission in active steroid-dependent IBD. These
patients had previously failed thiopurine monotherapy and a fifth of
patients had failed anti-TNF treatment. These observations should
alleviate existing anxiety regarding the safety of this therapeutic
Furthermore, this controlled study confirms observations of an
improvement in safety helped by an enhanced therapeutic window
of this combination. Notably, this is the first study to capture the
rapid clinical improvement associated, anecdotally up to now, with
combination therapy (as early as week 2 in ulcerative colitis and
week 4 in Crohn’s). This potential for rapid response enhances the
appeal for low-dose thiopurine allopurinol co-therapy.
Regarding the primary outcome, the trial did not reveal a differ-
ence between the 50 mg and 100 mg allopurinol dose. In our clinical
practice, we start with 100 mg allopurinol as it is well tolerated and
“hepatoprotective.” We have observed that in 10% receiving 100 mg
of allopurinol for azathioprine-induced hepatoxicity, liver function is
normalised with 200 mg of allopurinol.
© 2018 John Wiley & Sons Ltd