Comparing potassium-competitive acid blocker-based therapies for Helicobacter pylori infection: A Bayesian network...

Eradication rates for Helicobacter pylori (H. pylori) with proton pump inhibitor (PPI)-based therapy have declined due to rising resistance and pharmacokinetic limitations. Several potassium-competitive acid blockers (PCABs) are now approved for H. pylori eradication. However, direct comparisons among PCABs-based regimens are limited.

To evaluate the efficacy, safety and compliance of PCAB-based regimens for H. pylori eradication.

Randomised controlled trials in adults with H. pylori infection, evaluating PCAB-based dual, triple, or bismuth quadruple regimens or comparing PCAB- with PPI-based regimens, were included. The primary outcome was eradication rate; secondary outcomes were compliance and adverse events. Proportional meta-analysis and Bayesian network meta-analysis (NMA) with a random-effects model were conducted to compare efficacy and safety. Pooled estimates were expressed in odd ratio (OR) and corresponding 95% confidence intervals (CIs). Ranking used surface under the cumulative ranking curve (SUCRA). Subgroup analyses were conducted to explore potential sources of heterogeneity.

Seventy-seven RCTs involving 19,950 patients were included. Vonoprazan (VPZ)-based regimens showed the highest eradication rates in proportional meta-analysis (88.15-91.94%), while tegoprazan (TPZ)- and keverprazan (KEV)-based regimens demonstrated more variable performance. NMA demonstrated a significantly higher eradication rate in patients treated with VPZ-based quadruple regimen compared with VPZ-based dual (OR = 1.47, 95% CI 1.05-2.07) and TPZ-based triple (OR = 3.54, 95% CI 1.21-10.65) regimen. SUCRA ranking identified VPZ-based quadruple as the highest-ranked regimen (93.78%), followed by VPZ-based triple (70.55%) and TPZ-based quadruple (66.22%) regimen, indicating relative treatment ranking probabilities. Compliance rates were comparable across regimens with no significant differences, while VPZ- and TPZ-based dual therapies showed better safety profiles with lower adverse events than quadruple therapies (OR = 0.39-0.42).

VPZ-based quadruple therapy demonstrated the highest eradication efficacy among PCAB-based regimens, with significantly superior performance compared with selected dual and triple therapies. VPZ-based dual therapy appears to have a better balance of efficacy and safety profile. However, as 76 of 77 included trials were conducted in Asian populations, these findings should be interpreted with caution when extrapolating to non-Asian settings.

https://www.crd.york.ac.uk/PROSPERO/home ID= CRD420251125759 identifier CRD420251125759.