Vonoprazan-containing therapy has an H pylori eradication rate >90% and increases eradication vs. standard triple therapy

A systematic review and network meta-analysis of 68 randomized controlled trials compared the efficacy of empiric first-line regimens to treat Helicobacter pylori infection. A total of 22,975 study participants were randomized to eight first-line regimens. Vonoprazan triple therapy and reverse hybrid therapy achieved high eradication rates of greater than 90% compared with standard triple therapy; however, vonoprazan is not yet available in Europe and the U.S. Levofloxacin triple therapy achieved the highest eradication rates in Western countries. Standard triple therapy was the least efficacious regimen in the meta-analysis.

The study was published in the August Gastroenterology. The following commentary by Rashid N. Lui, MBChB, and Francis K.L. Chan, MD, appeared in the ACP Journal Club section of the October Annals of Internal Medicine.

The systematic review and network meta-analysis by Rokkas and colleagues provide an overview of the current evidence regarding the eradication rates for H pylori infection in the first-line setting. A network meta-analysis is an appropriate method to assess the multitude of regimens for eradicating H pylori infection with consistent estimates of the relative effects and to rank them coherently.

The review found that vonoprazan-containing therapy and reverse hybrid therapy were associated with >90% eradication rates compared with standard triple therapy, although this was only statistically significant for the former based on studies conducted in Asia only. Of the therapies assessed in multiple geographical regions (reverse hybrid therapy and vonoprazan-containing therapy were not), the most effective regimens were levofloxacin-containing therapies, with eradication rates of 84% across all regions (78% in East Asia). Many of the regimens included in the review do not meet the requirements of the Kyoto global consensus, which recommends that only therapies that reliably produce eradication rates of ≥90% be used.

Some limitations of the review include the lack of information about antibiotic resistance patterns, which was acknowledged by the authors. In addition, the paucity of data for vonoprazan outside of Asia limits its applicability in other parts of the world. Only 1 included trial assessed reverse hybrid therapy, which probably contributed to the wide confidence intervals. The arbitrary segregation of world regions into the West, West Asia, and East Asia is also not particularly informative given the diverse populations and countries involved.

Although promising, vonoprazan-containing regimens are not a silver bullet as, even in Japan where this is available, recent studies have reported that eradication rates can drop to ≤90% for clarithromycin-resistant strains of H pylori.

In an era of personalized medicine, this review supports a shift toward a susceptibility-based approach based on principles of antimicrobial stewardship, as is used with other infectious agents.