Cost-Effectiveness of First-Line Regimens for Helicobacter pylori Infection in the United States

Helicobacter pylori infection remains a significant global health burden. The 2024 American College of Gastroenterology guideline recommended bismuth quadruple therapy (BQT) as the first-line treatment for treatment-naive patients. This study aimed to assess the cost-effectiveness of 5 regimens from a US healthcare payer perspective.

A Markov model was used to evaluate 5 H. pylori eradication regimens: (i) clarithromycin triple therapy, (ii) vonoprazan dual therapy, (iii) vonoprazan triple therapy, (iv) rifabutin triple therapy, and (v) BQT. We simulated a hypothetical cohort of treatment-naïve adults with H. pylori over 1-, 10-, 20-year and lifetime horizons. Model outcomes were measured in incremental cost-effectiveness ratios and net monetary benefit (NMB) at willingness-to-pay thresholds of $100,000 and $150,000/quality-adjusted life year. Deterministic and probabilistic sensitivity analysis was performed to assess model robustness.

BQT had the lowest lifetime cost per patient ($193,651) and was used as the reference. Rifabutin and vonoprazan triple therapies had incremental cost-effectiveness ratios of $45,971 and $290,572 per quality-adjusted life year gained, respectively. Clarithromycin triple and vonoprazan dual therapies were dominated by BQT. Rifabutin triple therapy had the highest NMB, followed by BQT. Scenario analysis confirmed that rifabutin triple therapy maintained the highest NMB over 10- and 20-year horizons. Sensitivity analyses identified eradication rates of BQT were among the most influential parameters. Probabilistic sensitivity analysis showed rifabutin triple therapy had the highest probability of being cost-effective at both willingness-to-pay thresholds, followed by BQT.

BQT was found to be the cost-effective first-line treatment. Rifabutin triple therapy was a cost-effective alternative. Policymakers should prioritize BQT and rifabutin triple therapy versus other therapies.