Helicobacter pylori eradication for immune thrombocytopenia reduces non-response and raises platelet counts:...

Helicobacter pylori (H. pylori) has been implicated in immune thrombocytopenia (ITP), but the magnitude and reliability of benefit from eradication therapy in randomized trials remain uncertain. We performed a PRISMA-guided, PROSPERO-registered (CRD420251149478) systematic review and meta-analysis restricted to randomized controlled trials (RCTs) comparing H. pylori eradication versus control in ITP. Random-effects models generated risk ratios (RRs) for categorical outcomes: complete response (CR), partial response (PR), overall response (CR + PR), no/minimal response (NR), and 1-year relapse, and mean differences (MDs) for platelet-count change at approximately 6 months. Heterogeneity was assessed using I² and τ². Robustness was evaluated using leave-one-out analyses and additional post hoc sensitivity analyses for clinically or statistically influential trials. Small-study effects were explored using funnel plots and Egger/Begg tests when sufficient studies were available. Eight RCTs (n = 297) across Asia and Latin America met inclusion. Eradication increased CR without statistical significance (RR 1.45, 95% CI 0.87-2.41; I²=40.9%) and did not change PR (RR 0.88, 0.57-1.36; I²=0%) or overall response (RR 1.04, 0.90-1.20; I²=35.9%). NR was significantly lower with eradication (RR 0.65, 0.49-0.85; I²=14.8%). Relapse at 1 year trended lower but was not significant (RR 0.49, 0.24-1.01; I²=0%). Platelet counts rose more after eradication at ~ 6 months (MD + 61.9 × 10⁹/L, 36.1-87.7; I²=74.9%). Leave-one-out analyses did not materially change the overall conclusions. In a post hoc sensitivity analysis excluding Tang 2013 from the platelet-change outcome because of unusually small reported SDs, the platelet-count benefit remained significant and heterogeneity decreased to I²=0%. Funnel plots and formal tests suggested small-study effects for CR and overall response, indicating that these estimates may be inflated; no/minimal response showed no evidence of asymmetry. In randomized trials, H. pylori eradication in ITP was associated with a lower risk of no/minimal response and a greater platelet-count increase, while effects on CR, PR, overall response, and relapse remained uncertain. Because CR and overall response showed evidence of small-study effects, the most robust categorical finding was the reduction in no/minimal response. Larger, adequately powered trials are needed to define which patients are most likely to benefit and to confirm the durability of platelet response.