Efficacy of tegoprazan-based bismuth quadruple therapy compared with bismuth quadruple therapy for Helicobacter pylori infection: A randomized, double-blind, active-controlled study

Comparative Efficacy and Safety of Potassium-Competitive Acid Blocker-Based Dual, Triple, and Quadruple Regimens for First-Line Helicobacter pylori Infection Treatment: A Systematic Review and Network Meta-Analysis

INTRODUCTION

In the last few years, numerous new potassium-competitive acid blocker (P-CAB)-based randomized controlled trials (RCTs) concerning the first-line regimens for Helicobacter pylori infection treatment from various countries have been published. However, no network meta-analysis (NWM) exists, which examines the comparative efficacy and safety of P-CAB-based dual, triple, and quadruple treatments, and, therefore, in this NWM, we examined this matter comparing efficacy and safety of these P-CAB-based regimens.

METHODS

Databases were searched for identification, screening, eligibility, and inclusion of relevant RCTs. Extracted data were entered into a Bayesian NWM, and the ranking order for each regimen was evaluated by means of the surface under the cumulative ranking area values.

RESULTS

Twenty-five eligible RCTs were included with 7,605 patients randomized to 6 first-line regimens, i.e. P-CAB dual therapy, P-CAB triple therapy, P-CAB quadruple therapy, PPI dual therapy, PPI triple therapy, and PPI quadruple therapy. The surface under the cumulative ranking area values (%) for these 6 regimens were 92.7, 62.5, 33.9, 75.1, 19.4, and 16.3, respectively. The comparative effectiveness ranking showed that P-CAB dual therapy regimen ranked first for efficacy and last for adverse effects and had the best profile for integrated efficacy-safety.

DISCUSSION

In this NWM concerning the comparative efficacy and safety of P-CAB-based dual, triple, and quadruple regimens for the first-line H. pylori infection treatment, the overall results showed that P-CAB-based dual treatment ranked first for efficacy with the best-integrated efficacy-safety profile. This is of importance, since the dual regimens overcome the crucial issue of clarithromycin resistance. Consequently, these findings are expected to be useful in helping clinical decision making and future guidelines.

Efficacy and safety of vonoprazan-amoxicillin dual therapy versus bismuth-containing quadruple therapy for patients with Helicobacter pylori infection: a meta-analysis

Introduction

This meta-analysis aims to compare the efficacy and safety of vonoprazan-amoxicillin (VA) dual therapy in comparison to bismuth-containing quadruple therapy (BQT) for patients with Helicobacter pylori (H. pylori) infection.

Materials and methods

Four databases (PubMed, Embase, Web of Science, and Cochrane Library) were searched published from establishment of database to June 1, 2024, for articles studying VA dual therapy compared to BQT for patients with H. pylori infection. Meta-analyses of eradication rates, adverse events, compliance and cost were preformed.

Results

A total of 17 studies were included for meta-analysis. Compared with BQT, VA increased the incidence of H. pylori eradication rate, with significant difference under the ITT analysis (86.9% vs. 80.4%, RR = 1.07, 95% CI: 1.01-1.12, p = 0.01) but there no significant difference under the PP analysis (90.7% vs. 86.5%, RR = 1.03, 95% CI: 0.99-1.08, p = 0.13). Besides, VA significantly increased compliance (RR = 1.03, 95% CI: 1.01-1.05, p < 0.01) and decreased the occurrence of total adverse events (27.0% vs. 11.5%, RR = 0.43, 95% CI: 0.37-0.51, p < 0.01). Furthermore, VA has lower cost compared to BQT.

Conclusion

Our findings indicated that VA dual therapy provided a higher eradication rate, enhanced compliance, decreased adverse events, and lowered cost relative to BQT for patients with H. pylori infection.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024576738, identifier CRD42024576738 (PROSPERO).

Tegoprazan-Containing Versus Proton Pump Inhibitor-Containing Therapy for First-Line Eradication of Helicobacter pylori: A Meta-Analysis of Randomized Controlled Trials

Introduction

Concerns have been raised regarding the decreasing success rates of the standard treatment of Helicobacter pylori (proton pump inhibitor (PPI) and two/three antibiotics) and the long-term effects carried by PPI. Despite conflicting data, Tegoprazan, a potassium-competitive acid blocker, is hypothesized to be superior to PPI for eradicating H pylori. This systematic review and meta-analysis aim to determine the superiority of Tegoprazan-containing therapy to PPI-containing therapy for H pylori eradication.

Methods

A systematic literature search identified studies published until December 12, 2024, from MEDLINE, EMBASE, SCOPUS, and CENTRAL. The search strategy included the following keywords: "Tegoprazan," "Proton Pump Inhibitors," and "Helicobacter pylori." Only randomized controlled trials (RCTs) that compared the efficacy of Tegoprazan to any PPI were included. Risk of bias assessment was performed using the Cochrane Risk of Bias 2 (RoB2) tool for RCTs. The random-effect model was used to calculate the pooled risk ratio (RR) and its 95% Confidence Interval (95% CI) from the intention-to-treat population.

Results

Six RCTs with low risks of bias were included in this meta-analysis. All studies included treatment-naïve patients and compared first-line H pylori treatment. The overall eradication rates of Tegoprazan-containing (N = 1052) versus PPI-containing therapy (N = 1058) were 83.37% and 80.06%, respectively (RR 1.045; 95% CI 1.008-1.084; I 2 = 0%). Tegoprazan-containing therapy demonstrated comparable treatment-emergent adverse event (TEAE) rates compared to PPI-containing therapy (46.48% vs. 46.31%; RR 1.026; 95% CI 0.952-1.106; I 2 = 48%).

Conclusion

This meta-analysis demonstrated that Tegoprazan-containing therapy is superior to PPI-containing therapy for first-line H pylori eradication, with comparable safety profiles.

Seven-Day Versus 14-Day Tegoprazan and Tetracycline-Containing Quadruple Therapy for First-Line Eradication of Helicobacter pylori Infection: A Randomized, Open-Label, Noninferiority Trial

BACKGROUND AND AIMS

Tegoprazan, a new class of drugs, is a potassium-competitive acid blocker (P-CAB) that inhibits gastric H+/K+-ATPase through a different mechanism than proton pump inhibitor. Tetracycline also has anti-Helicobacter pylori properties. However, only a few randomized controlled trials (RCTs) have investigated the efficacy of tegoprazan and tetracycline-containing quadruple therapy (TTQT) for treating H. pylori infections, which this RCT explored.

METHODS

This multicenter RCT included treatment-naïve adults with H. pylori infection who received 7 or 14 days of TTQT (50-mg tegoprazan, 220-mg bismuth potassium citrate, and 1000-mg amoxicillin twice daily with 500-mg tetracycline four times daily). The primary outcome was the eradication rate; secondary endpoints included the incidence of adverse events, treatment compliance, and regimen costs.

RESULTS

The study included 258 patients. The eradication rates in the 7- and 14-day groups were 90.70% (117/129, 95% confidence interval [CI]: 83.98%-94.89%) and 91.47% (118/129, 95% CI: 84.90%-95.45%), respectively, in the intention-to-treat analysis (difference: -0.78%; -7.01%-8.58%; noninferiority p < 0.001); 92.86% (117/126, 95% CI: 86.50%-96.48%) and 93.65% (118/126, 95% CI: 87.47%-97.02%), respectively, in the modified intention-to-treat analysis (difference: 0.79%; 95% CI: -6.36%-7.99%; noninferiority p < 0.001); and 94.35% (117/124, 95% CI: 88.29%-97.50%) and 95.12% (117/123, 95% CI: 89.24%-98.00%), respectively, in the per-protocol analysis (difference: -0.77%; 95% CI: -5.91%-7.48%; noninferiority p < 0.001). Significantly fewer adverse events occurred in the 7-day group than in the 14-day group (22.48% vs. 35.67%, p = 0.020). Treatment compliance did not differ between the two groups.

CONCLUSIONS

The 7- and 14-day TTQT efficacies for the first-line treatment of H. pylori infection were comparable, and fewer adverse effects occurred in the 7-day group. This trial has been registered at Clinical Trials.gov (NCT05997433).

Comparison of tegoprazan and proton pump inhibitors for first-line Helicobacter pylori eradication: a systematic review with meta-analysis

BACKGROUND

Tegoprazan (TPZ), a potassium-competitive acid blocker with potent gastric acid-suppressing activity, may be a potential agent for treating Helicobacter pylori infection. The study aimed to evaluate the efficacy of TPZ-based therapy for H. pylori eradication compared with proton pump inhibitor (PPI)-based therapy.

RESEARCH DESIGN AND METHODS

A comprehensive literature search was conducted up to August 2024 using PubMed, Embase, and the Cochrane Library to investigate the beneficial effects of TPZ-based therapy for H. pylori eradication. Studies that evaluated the eradication rates between the TPZ- and PPI-based therapies were included. The authors conducted a meta-analysis to calculate the eradication rate and pooled risk ratio (RR) with a 95% confidence interval.

RESULTS

Seven studies involving 3200 patients were included. H. pylori eradication rates did not differ significantly between the TPZ- and PPI-based therapies based on the intention-to-treat (77.3% vs. 76.4%, p = 0.68; pooled RR = 1.01 [0.97-1.05]) and per-protocol (84.3% vs. 84.2%, p = 0.69; pooled RR = 1.01 [0.98-1.04]) analyses. Additionally, no significant difference was observed in the adverse drug events between TPZ- and PPI-based therapies (27.2% vs. 30.8%, p = 0.26; pooled RR = 0.91 [0.76-1.08]).

CONCLUSIONS

H. pylori eradication and adverse drug event rates with TPZ- and PPI-based treatments were similar.

The efficacy and safety of Vonoprazan and Tegoprazan in Helicobacter pylori eradication: a comprehensive systematic review and meta-analysis of randomized controlled trials

Background

Potassium-competitive acid blocker (P-CAB)-based therapies are emerging as promising alternatives for eradicating Helicobacter pylori infection. However, the comparative efficacy of P-CAB-based therapy versus proton-pump inhibitor (PPI)-based therapy in treating H. pylori infection remains uncertain.

Objectives

This meta-analysis evaluated the efficacy and safety of P-CAB-based therapies, including Vonoprazan (VPZ) and Tegoprazan (TPZ), compared to PPI-based therapies for H. pylori infection. Subgroup analysis assessed the influence of drug history, experimental drug, treatment duration, combination therapies, and geographic regions on treatment outcomes.

Design

Meta-analysis.

Data sources and methods

Comprehensive searches were conducted in major databases, including PubMed, Embase, the Cochrane Library, and Web of Science, up to January 1, 2024. The primary outcome was the eradication rate, analyzed by intention-to-treat (ITT). Secondary outcomes included adverse events. Heterogeneity among studies was assessed using the χ2 test and the I 2 test. I 2 > 50% or p < 0.05 indicated significant heterogeneity.

Results

The analysis totally included 28 randomized controlled trials (RCTs) comprising 37 studies and 8818 patients diagnosed with H. pylori infection. Of these, 14 RCTs, including 20 studies and 4286 patients, compared P-CAB-based therapy with 14-day bismuth-based quadruple therapy (BQT). P-CAB-based therapy exhibited superior eradication rates compared to both 14-day BQT and PPI-based therapy (ITT analysis: 87.0% vs 79.8%, risk ratio (RR) = 1.08, 95% CI: 1.04-1.12, p < 0.0001; and 85.6% vs 77.8%, RR = 1.09, 95% CI: 1.05-1.12, p < 0.00001, respectively). This enhanced efficacy was particularly pronounced in patients with clarithromycin-resistant infections (73.7% vs 41.5%, RR = 1.53, 95% CI: 1.07-2.20, p = 0.02). Subgroup analysis demonstrated higher eradication rates with P-CAB-based therapy in treatment-naïve participants, VPZ recipients, and those receiving 7- or 14-day regimens (dual, triple, or quadruple therapy). However, no significant differences were observed in treatment-experienced subgroups, TPZ recipients, or those on 10-day regimens. In addition, P-CAB-based therapy showed a lower incidence of adverse events than PPI-based treatments (RR = 0.73, 95% CI: 0.63-0.86, p < 0.0001).

Conclusion

P-CAB-based therapies are more effective than traditional PPI-based treatments for eradicating H. pylori infection, with a reduced incidence of adverse events.

PROSPERO registration

CRD42024503665.

Comparative efficacy of Helicobacter pylori eradication therapy between tegoprazan-based concomitant and bismuth quadruple therapies: A real-world evidence

BACKGROUND AND AIM

Tegoprazan, a potassium-competitive acid blocker, can be used as a substitute for proton pump inhibitors in Helicobacter pylori eradication therapy; some studies have reported improved efficacy. In Korea, where clarithromycin resistance rates are high, we aimed to compare the efficacies of tegoprazan-based concomitant and bismuth quadruple therapies.

METHODS

We retrospectively analyzed data from patients with H. pylori infection who received either 10-day tegoprazan-based concomitant therapy or 14-day tegoprazan-based bismuth quadruple therapy as first-line treatment. The primary outcome was H. pylori eradication rate, with secondary outcomes including adverse events and insufficient medication rates.

RESULTS

Among the 1082 patients included in the study, 620 and 462 were treated with tegoprazan-based concomitant and bismuth quadruple therapies, respectively. Intention-to-treat analysis demonstrated no difference in eradication rates between the tegoprazan-based concomitant and bismuth quadruple therapy groups (74.7% [95% confidence interval-CI, 71.1-78.0%] vs 74.7% [95% CI, 70.6-78.5%], P = 0.999). Per-protocol analysis also showed similar eradication rates between the two groups (88.0% [95% CI, 85.0-90.6%] vs 89.7% [95% CI, 86.3-92.5%], P = 0.424). The overall adverse event rates (49.6% vs 39.2%, P = 0.001) and insufficient medication rates (4.8% vs 2.4%, P = 0.036) were higher in the bismuth quadruple therapy group than in the concomitant therapy group.

CONCLUSIONS

The eradication rates of tegoprazan-based 10-day concomitant therapy and 14-day bismuth quadruple therapy were comparable. However, because of its shorter treatment duration, better medical adherence, and lower incidence of adverse events, tegoprazan-based concomitant therapy may be preferable in regions with high rates of clarithromycin and metronidazole resistance.

Comparative Efficacy and Safety of Potassium-Competitive Acid Blockers and Proton Pump Inhibitors for First-Line Helicobacter pylori Eradication Therapy: A Systematic Review and Network Meta-Analysis

BACKGROUND

Given the increasing antibiotic resistance and the inadequate acid-suppressing effects of proton pump inhibitors (PPIs), it is crucial to continuously optimize existing Helicobacter pylori (H. pylori) treatment regimens. This study aimed to evaluate the clinical efficacy and safety of novel potassium-competitive acid blocker (P-CAB)-based eradication regimens compared with traditional PPI-based regimens for the initial treatment of H. pylori.

MATERIALS AND METHODS

We conducted a systematic review and network meta-analysis, searching seven electronic databases for randomized controlled trials (RCTs) evaluating initial P-CAB-based H. pylori eradication therapy. The primary outcome was the H. pylori eradication rate. Secondary outcomes included adverse events and patient compliance. We synthesized the effect sizes of the trials using odds ratios (OR) and 95% confidence intervals (95% CI).

RESULTS

A total of 54 RCTs involving 15,320 patients (74.9% male, mean age 30.2 years) were included in this study. In the intention-to-treat (ITT) analysis, VPZ-HD-dual, VPZ-triple, and VPZ-quadruple regimens demonstrated significantly higher eradication rates than PPI-triple, PPI-quadruple, and VPZ-dual regimens. Similar trends were observed in the per-protocol (PP) analysis. Subgroup analysis indicated that poor patient compliance significantly reduced eradication rates. Resistance to clarithromycin and metronidazole significantly weakened the eradication effects of PPI-triple, TPZ-triple, and VPZ-triple regimens. Additionally, the eradication rates for 7-day regimens were significantly lower than those for 14-day or 10-day regimens, but there was no significant difference between the eradication rates of 10-day and 14-day regimens. Notably, the risk of adverse events with VPZ-HD-dual was significantly lower than with VPZ-quadruple.

CONCLUSION

Vonoprazan combined with high-dose amoxicillin dual therapy not only provides satisfactory eradication rates but also exhibits lower adverse event rates and good patient compliance, indicating its potential as a promising regimen for further promotion.

Potassium-competitive Acid Blockers: Current Clinical Use and Future Developments

PURPOSE OF THE REVIEW

Acid suppression with proton pump inhibitors (PPIs) represents the standard of care in the treatment of acid-related diseases. However, despite their effectiveness, PPIs display some intrinsic limitations, which underlie the unmet clinical needs that have been identified over the past decades. The aims of this review are to summarize the current status and future development of the new class of antisecretory drugs (potassium-competitive acid blockers, P-CABs) that have recently been introduced into medical practice.

RECENT FINDINGS

Over the past decades, clinical needs unmet by the current acid suppressants have been recognized, especially in the management of patients with GERD, Helicobacter pylori infection and NSAID-related peptic ulcer. The failure to address these needs is mainly due to their inability to achieve a consistent acid suppression in all patients and, particularly, to control nighttime acidity. It was then realized that an extended duration of acid suppression would exert additional benefits. The available data with P-CABs show that they are able to address these unmet clinical needs. Four different P-CABs (vonoprazan, tegoprazan, fexuprazan and keverprazan) are currently available. However, only two of them are approved outside Asia. Vonoprazan is available in North, Central and South America while tegoprazan is marketed only in Latin American countries. Two other compounds (namely linazapran glurate and zestaprazan) are presently under clinical development. While clinical trials on GERD have been performed with all P-CABs, only vonoprazan and tegoprazan have been investigated as components of Helicobacter pylori eradication regimens. The available data show that-in the above two clinical indications-P-CABs provide similar or better efficacy in comparison with PPIs. Their safety in the short-term overlaps that of PPIs, but data from long-term treatment are needed.

Efficacy of Tegoprazan-Containing Sequential Eradication Treatment Compared to Esomeprazole-Containing Sequential Eradication of Helicobacter pylori in South Korea, a Region With High Antimicrobial Resistance: A Prospective, Randomized, Single Tertiary Center Study

BACKGROUND

Treatment with potassium-competitive acid blockers has shown acceptable efficacy in Helicobacter pylori eradication. In regions like Korea, where the clarithromycin resistance rate is high, alternative combinations like non-bismuth quadruple therapies have shown favorable results. This study compared the outcomes of sequential eradication therapy with new potassium-competitive acid blocker tegoprazan and conventional esomeprazole-containing sequential therapy.

MATERIALS AND METHODS

Patients with Helicobacter pylori (H. pylori) infection were consecutively recruited. Patients were allocated to either an esomeprazole-containing sequential or a tegoprazan-containing sequential therapy group. Sequential therapy comprised esomeprazole (40 mg) or tegoprazan (50 mg) plus amoxicillin (1000 mg) twice daily for the initial 5 days, followed by esomeprazole (40 mg) or tegoprazan (50 mg) with clarithromycin (500 mg) and metronidazole (500 mg) twice daily for the remaining 5 days. Eradication rate, compliance, and adverse events were recorded.

RESULTS

A total of 406 patients with H. pylori infection were enrolled in the trial and analyzed per protocol. Eradication rate by intention-to-treat and per-protocol was 83.8% (95% confidence interval [CI]: 78.7-88.9) for esomeprazole-containing sequential therapy, and 87.1% (95% CI: 82.5-91.8) for tegoprazan-containing sequential therapy, with no statistical significance (p = 0.399). Additionally, there was no statistically significant difference in treatment compliance between the two groups. Nausea was more prevalent (23.3%, 27/202) with sequential tegoprazans than with esomeprazole-containing sequential therapy (14.2%, 29/204; p = 0.022).

CONCLUSION

Tegoprazan-containing 10-day sequential eradication treatment demonstrated similar eradication efficacy compared to esomeprazole-containing treatment, even in regions with high antimicrobial resistance, such as Korea.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT06382493.

Fourteen-Day Tegoprazan-Amoxicillin Dual Therapy as the First-Line Treatment of Helicobacter pylori Infection (SHARE2301): A Multicenter, Noninferiority, Randomized Clinical Trial

BACKGROUND

Potassium-competitive acid blockers have demonstrated enormous potential in the eradication treatment of Helicobacter pylori infection, with tegoprazan being one of the representatives. The available data on the safety and efficacy of tegoprazan in dual therapy are limited.

MATERIALS AND METHODS

The multicenter, noninferiority, randomized-controlled trial was conducted from May 2023 to March 2024. Treatment-naive subjects were randomly assigned (1:1) to enter either the tegoprazan-amoxicillin (TA) group (tegoprazan 50 mg twice daily and amoxicillin 750 mg four times daily) or the esomeprazole-amoxicillin (EA) group (esomeprazole 20 mg and amoxicillin 750 mg all four times daily), with a duration for 14 days. The primary outcome was eradication rate as determined by 13C-urea breath test, including per-protocol (PP) analysis and intention-to-treat (ITT) analysis. Secondary outcomes were adverse events and compliance.

RESULTS

A total of 368 individuals were included in the randomization. The eradication rates in the EA group and the TA group were 84.2% and 85.8%, respectively, according to an ITT analysis (p = 0.77), and 88.5% and 88.2%, respectively, according to PP analysis (p = 1.00). The eradication rates for the TA group were not inferior to those of the EA group in both PP (p = 0.0023) and ITT analyses (p = 0.0009). There were no significant statistical differences in the incidence of adverse events and compliance between the two groups. The multivariate logistic regression analysis revealed that poor compliance increased the risk of eradication failure (p < 0.001).

CONCLUSIONS

Dual therapy containing tegoprazan is safe and effective to be considered as a clinical first-line treatment option, but further optimization involving antimicrobial susceptibility testing and adjustments in dosage and frequency is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT05870683.

Pharmacokinetic Interactions Between Tegoprazan and the Combination of Clarithromycin, Amoxicillin and Bismuth in Healthy Chinese Subjects: An Open-Label, Single-Center, Multiple-Dosage, Self-Controlled, Phase I Trial

BACKGROUND

Tegoprazan is a potassium-competitive acid blocker that inhibits gastric acid and which may be used for eradicating Helicobacter pylori. This study focuses on the pharmacokinetic interaction and safety between tegoprazan and the combination of clarithromycin, amoxicillin and bismuth in healthy Chinese subjects.

METHODS

An open-label, three-period, single-center, multiple-dosage, single-sequence, phase I trial was conducted in 22 healthy subjects. In period 1, the subjects took tegoprazan 50 mg twice daily for 7 days, and in period 2 they were administered clarithromycin 500 mg, amoxicillin 1000 mg and bismuth potassium citrate 600 mg twice daily for 7 days (days 14-20). Tegoprazan, clarithromycin, amoxicillin and bismuth potassium citrate were then administered in combination for 7 days (days 21-27) in period 3. Blood samples were collected up to 12 h after the last dose of each period. Safety assessments were performed in each period.

RESULTS

The geometric mean ratios (GMRs) [90% confidence interval (CI)] of maximum plasma concentration at steady state (Cmax,ss) and area under the plasma concentration-time curve over the dosing interval (AUCτ) at steady state were 195.93% (175.52-218.71%) and 287.54% (263.28-314.04%) for tegoprazan and 423.23% (382.57-468.22%) and 385.61% (354.62-419.30%) for tegoprazan metabolite M1, respectively. The GMRs (90% CI) of Cmax,ss and AUCτ were 83.69% (77.44-90.45%) and 110.30% (102.74-118.41%) for clarithromycin, 126.25% (114.73-138.93%) and 146.94% (135.33-159.55%) for 14-hydroxyclarithromycin, 75.89% (69.73-82.60%) and 94.34% (87.94-101.20%) for amoxicillin, and 158.43% (125.43-200.11%) and 183.63% (156.42-215.58%) for bismuth, respectively. All reported adverse events were mild. The frequency of adverse events during the coadministration stage was not higher than that during the single- or triple-drug administration stages.

CONCLUSION

The plasma exposure of tegoprazan, M1, 14-hydroxyclarithromycin and bismuth was increased after the coadministration of tegoprazan, clarithromycin, amoxicillin and bismuth. The coadministration exhibited favorable safety and tolerability.

CLINICAL TRIALS REGISTRATION

CTR20230643.

Treatment of Helicobacter pylori with potassium competitive acid blockers: A systematic review and meta-analysis

BACKGROUND

Helicobacter pylori (H. pylori) infects over half the global population, causing gastrointestinal diseases like dyspepsia, gastritis, duodenitis, peptic ulcers, G-MALT lymphoma, and gastric adenocarcinoma. Eradicating H. pylori is crucial for treating and preventing these conditions. While conventional proton pump inhibitor (PPI)-based triple therapy is effective, there's growing interest in longer acid suppression therapies. Potassium competitive acid blocker (P-CAB) triple and dual therapy are new regimens for H. pylori eradication. Initially used in Asian populations, vonoprazan (VPZ) has been recently Food and Drug Administration-approved for H. pylori eradication.

AIM

To assess the efficacy of regimens containing P-CABs in eradicating H. pylori infection.

METHODS

This study, following PRISMA 2020 guidelines, conducted a systematic review and meta-analysis by searching MEDLINE and Scopus libraries for randomized clinical trials (RCTs) or observational studies with the following command: [("Helicobacter pylori" OR "H pylori") AND ("Treatment" OR "Therapy" OR "Eradication") AND ("Vonaprazan" OR "Potassium-Competitive Acid Blocker" OR "P-CAB" OR "PCAB" OR "Revaprazan" OR "Linaprazan" OR "Soraprazan" OR "Tegoprazan")]. Studies comparing the efficacy of P-CABs-based treatment to classical PPIs in eradicating H. pylori were included. Exclusion criteria included case reports, case series, unpublished trials, or conference abstracts. Data variables encompassed age, diagnosis method, sample sizes, study duration, intervention and control, and H. pylori eradication method were gathered by two independent reviewers. Meta-analysis was performed in R software, and forest plots were generated.

RESULTS

A total of 256 references were initially retrieved through the search command. Ultimately, fifteen studies (7 RCTs, 7 retrospective observational studies, and 1 comparative unique study) were included, comparing P-CAB triple therapy to PPI triple therapy. The intention-to-treat analysis involved 8049 patients, with 4471 in the P-CAB intervention group and 3578 in the PPI control group across these studies. The analysis revealed a significant difference in H. pylori eradication between VPZ triple therapy and PPI triple therapy in both RCTs and observational studies [risk ratio (RR) = 1.17, 95% confidence interval (CI): 1.11-1.22, P < 0.0001] and (RR = 1.13, 95%CI: 1.09-1.17, P < 0.0001], respectively. However, no significant difference was found between tegoprazan (TPZ) triple therapy and PPI triple therapy in both RCTs and observational studies (RR = 1.04, 95%CI: 0.93-1.16, P = 0.5) and (RR = 1.03, 95%CI: 0.97-1.10, P = 0.3), respectively.

CONCLUSION

VPZ-based triple therapy outperformed conventional PPI-based triple therapy in eradicating H. pylori, positioning it as a highly effective first-line regimen. Additionally, TPZ-based triple therapy was non-inferior to classical PPI triple therapy.

Efficacy and Safety of Potassium-Competitive Acid Blockers Versus Proton Pump Inhibitors as Helicobacter pylori Eradication Therapy: A Meta-Analysis of Randomized Clinical Trials

Helicobacter pylori is a gram-negative bacterium that chronically infects the gastric epithelium. Potassium-competitive acid blockers (P-CABs) are a promising alternative, being more potent than standard proton pump inhibitors (PPIs). The meta-analysis followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria were randomized controlled trials (RCTs) comparing P-CAB and PPI-based therapy, confirmed H. pylori infection, and measured eradication rates after at least four weeks. Subgroup analyses were conducted based on therapy type and trial location. Quality assessment used the Cochrane risk-of-bias tool, RoB 2.0, and statistical analysis was performed using ReviewManager (RevMan) 5.4 (2020; The Cochrane Collaboration, London, United Kingdom). A p-value of <0.05 is considered statistically significant. In the intention-to-treat (ITT) analysis, P-CABs demonstrated superior overall efficacy, consistently observed in the first-line treatment subgroup. However, no significant difference was found in the subgroup receiving salvage therapy. Another ITT subgroup analyzed the impact of geographical location, favoring P-CABs in the overall study population and the Japanese subgroup. However, no statistically significant differences were found in the subgroups of other countries. In the PPA, P-CABs showed superior efficacy overall, consistently seen in the first-line treatment subgroup. However, no significant difference was found in the subgroup receiving salvage eradication therapy. Another PPA subgroup analysis considered the geographical impact on eradication rates, revealing P-CABs as superior to PPIs in the overall study population and the Japanese subgroup, but not in other countries. No significant adverse event outcomes were observed. P-CAB-based triple therapy is more effective than PPI-based triple therapy as the primary treatment for H. pylori eradication, particularly in Japanese patients. Nevertheless, regarding salvage therapy, both treatments show comparable efficacy. Additionally, the tolerability of P-CAB-based and PPI-based triple therapy is similar, with a similar occurrence of adverse events.