Vonoprazan‐based therapies versus PPI‐based therapies in patients with H. pylori infection: Systematic review and meta‐analyses of randomized controlled trials

Abstract Background This study aims to evaluate the efficacy and safety of vonoprazan‐amoxicillin (VA), vonoprazan‐amoxicillin‐clarithromycin (VAC), vonoprazan‐based bismuth‐containing quadruple therapy (VBQT), and PPI‐based triple (PAC) or quadruple therapy (PBQT) for H. pylori infection with the consideration of duration of therapy and amoxicillin dose (H: high; L: low). Materials and Methods PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched for eligible randomized controlled trials (RCTs) up to December 15, 2023. The efficacy outcome was eradication rate, and safety outcomes included the rates of adverse events and treatment discontinuation. Results Twenty‐seven RCTs were included. The pooled eradication rates were 82.8% for VA, 89.1% for VAC, and 91.8% for VBQT, which increased with the higher amoxicillin frequency of administration and extended duration of therapy within each regimen. There were no significant differences in eradication rate when comparing 7‐VA versus 7‐VAC and 14‐VA versus 14‐VAC. VA was at least comparable to PAC. The eradication rate did not differ significantly between 10‐H‐VA or 14‐H‐VA versus 14‐PBQT. 7‐L‐VAC demonstrated higher eradication rate versus 7‐PAC and comparable rate to 14‐PAC. 14‐VBQT showed higher eradication rates versus 14‐PBQT. The adverse events rate was 19.3% for VA, 30.6% for VAC, and 38.4% for VBQT. VA had similar risk of adverse events versus VAC and significantly fewer adverse events compared to PBQT. The treatment discontinuation rate did not differ significantly between treatments. Conclusions The eradication rate of VBQT was the highest at above 90% followed by VAC and VA. VA was as effective as VAC and superior to PPI‐based therapies with favorable safety, highlighting the potential of VA therapy as a promising alternative to traditional PPI‐based therapies. VPZ‐based triple or quadruple therapies was more effective than PPI‐based therapies. Further studies are needed to establish the optimal treatment regimen especially in the western countries.