Vonoprazan-Based Triple Therapy: Most Effective Worldwide for Helicobacter pylori

Researchers performed a network meta-analysis to compare the effectiveness of first-line regimens vs standard triple therapy in the treatment of H pylori infection.

Among first-line dual, triple, and quadruple therapies for Helicobacter pylori (H pylori) infection, vonoprazan-based triple therapy has been demonstrated to be the most effective worldwide, with standard triple therapy being the least efficacious, according to a network meta-analysis (NWM) published in Gastroenterology.

While several double, triple, and quadruple therapies have been suggested as first-line empiric treatment for H pylori infection, knowledge of their worldwide and regional comparative efficacy is lacking. Therefore, researchers examined the comparative effectiveness of all empirically used first-line regimens tested against standard triple treatment using a NWM of published randomized controlled trials (RCTs).

Investigators extracted data from 68 eligible RCTs, which were entered into a Bayesian NWM to investigate the comparative efficacy of empiric first-line regimens in their treatment of H pylori infection and to rank them by effectiveness. The ranking probability for each regimen was evaluated by means of surfaces under cumulative ranking values (SUCRA).

A total of 92 paired comparisons with 22,975 patients randomized to 8 first-line regimens were included. The overall results showed that only vonoprazan triple therapy and reverse hybrid therapy achieved cure rates of more than 90%. Levofloxacin triple therapy performed best in Western countries with an eradication rate 88.5%. In addition, the comparative effectiveness ranking showed that vonoprazan triple therapy performed best overall, whereas standard triple therapy was the least effective regimen (SUCRA 92.4% vs 4.7% respectively).

This study was limited by a lack of data regarding the resistance of H pylori to antibiotics, preventing further subgroup analysis.

“As increasing antibiotic resistance continues to emerge and impairs clinicians’ ability to cure H pylori infection, the results of this NWM might suggest that a new approach concerning H pylori treatment is now needed and that the time for transitioning from trial and error to antimicrobial stewardship, has arrived,” concluded the authors. They added, “This approach is expected to be useful in helping future guidelines and clinical decision making.”

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. 


Rokkas T, Gisbert JP, Malfertheiner P, et al. Comparative effectiveness of multiple different first-line treatment regimens for Helicobacter pylori infection: a network meta-analysis. Gastroenterol. doi: 10.1053/j.gastro.2021.04.012