Medicine by the Numbers

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Comparison of Treatment Regimens for Helicobacter pylori Infection

 

Am Fam Physician. 2021 Sep ;104(2):online.

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TREATMENTS FOR HELICOBACTER PYLORI INFECTION

BenefitsHarms

Overall cure rates were 93.6% for reverse hybrid therapy, 91.4% for vonoprazan-based triple therapy, 84.3% for nonbismuth quadruple therapy, and 83.8% for levofloxacin-based triple therapy.

Not reported

In Western countries, levofloxacin-based therapy had the highest cure rate of 88.5%.

TREATMENTS FOR HELICOBACTER PYLORI INFECTION

BenefitsHarms

Overall cure rates were 93.6% for reverse hybrid therapy, 91.4% for vonoprazan-based triple therapy, 84.3% for nonbismuth quadruple therapy, and 83.8% for levofloxacin-based triple therapy.

Not reported

In Western countries, levofloxacin-based therapy had the highest cure rate of 88.5%.

Details for This Review

Study Population: 68 randomized controlled trials (RCTs) comprising 22,975 patients with Helicobacter pylori infection

Efficacy End Points: Cure rates

Harm End Points: Not assessed

Narrative: H. pylori is a common infection associated with gastritis, peptic ulcers, gastric cancer, and mucosa-associated lymphoid tissue lymphoma.1 Current guidelines recommend treatment for all individuals with H. pylori infection to reduce complications.2,3 Despite a range of therapy options and regimens, cure rates are lower than treatments for other infectious diseases.1,46 A potassium-competitive acid blocker, vonoprazan (Takecab), was approved for use in Japan in 2015 to improve cure rates in patients with H. pylori infection, but it is not approved for use in the United States.7

This network meta-analysis included RCTs evaluating the effectiveness of empiric first-line dual, triple, and quadruple treatment regimens of seven days or longer for H. pylori infection.6 A network meta-analysis allows for direct and indirect comparison of treatment arms from different trials.8,9 The primary outcome of this meta-analysis was infection cure rate, and the authors subsequently ranked the overall effectiveness of each regimen. The authors also used surface under the cumulative ranking curve (SUCRA) values in intervention network charts to evaluate cumulative ranking probability for each intervention.9 The SUCRA value is used to evaluate which treatment is the most effective, ranging from 0% to 100%. Treatments with higher SUCRA values are considered more effective, and treatments with lower SUCRA values are considered less effective.9

The meta-analysis included 68 RCTs and 22,975 individuals. There were 56 two-arm and 12 three-arm RCTs, including 92 paired comparisons, which the authors grouped into 12 pairwise meta-analyses.6  A total of eight first-line treatment regimens allowed for 28 possible comparisons, of which 12 were direct and 16 were indirect (Table 1).6

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TABLE 1.

Cure Rates of Treatment Regimens for Helicobacter pylori Infection

RegimenCure rate percentage (95% CI)

OverallWestEast AsiaWest Asia

Reverse hybrid therapy*

93.6 (90.4 to 96.8)

93.6 (90.4 to 96.8)

Vonoprazan-based triple therapy†

91.4 (88.5 to 93.8)

91.4 (88.5 to 93.8)

Nonbismuth quadruple therapy‡

84.3 (82.7 to 85.8)

87.8 (84.0 to 91.2)

84.7 (82.8 to 86.4)

70.6 (63.5 to 77.1)

Levofloxacin-based therapy§

83.8 (82.1 to 85.4)

88.5 (86.5 to 90.5)

77.6 (74.3 to 80.7)

88.4 (84.6 to 91.1)

Sequential therapy||

83.7 (82.7 to 84.7)

87.9 (86.3 to 89.3)

82.6 (81.1 to 84.1)

82.7 (78.9 to 86.1)

Bismuth-based quadruple therapy¶

81.3 (79.5 to 83.1)

81.2 (78.3 to 83.8)

87.3 (84.8 to 86.6)

71.2 (64.5 to 77.3)

Amoxicillin-based dual therapy**

80.2 (75.3 to 84.4)

64.6 (51.7 to 76.8)

84.8 (80.3 to 88.6)

Standard triple therapy††

75.7 (74.9 to 76.4)

67.8 (66.3 to 69.3)

75.9 (74.7 to 77.8)

72.7 (67.7 to 77.3


*—Proton pump inhibitor and amoxicillin for 14 days, plus clarithromycin and metronidazole for the initial 7 days.

†—Vonoprazan, amoxicillin, and clarithromycin.

‡—Metronidazole, tetracycline, amoxicillin, and proton pump inhibitor.

§—Triple or quadruple therapy with levofloxacin.

||—Amoxicillin and proton pump inhibitor for 5 days, followed by clarithromycin and metronidazole.

¶—Bismuth subsalicylate, metronidazole, tetracycline, and proton pump inhibitor.

**—High-dose amoxicillin and proton pump inhibitor.

††—Proton pump inhibitor, tetracycline, and amoxicillin or metronidazole (Flagyl).

Information from reference 6.

TABLE 1.

Cure Rates of Treatment Regimens for Helicobacter pylori Infection

RegimenCure rate percentage (95% CI)

OverallWestEast AsiaWest Asia

Reverse hybrid therapy*

93.6 (90.4 to 96.8)

93.6 (90.4 to 96.8)

Vonoprazan-based triple therapy†

91.4 (88.5 to 93.8)

91.4 (88.5 to 93.8)

Nonbismuth quadruple therapy‡

84.3 (82.7 to 85.8)

87.8 (84.0 to 91.2)

84.7 (82.8 to 86.4)

70.6 (63.5 to 77.1)

Levofloxacin-based therapy§

83.8 (82.1 to 85.4)

88.5 (86.5 to 90.5)

77.6 (74.3 to 80.7)

88.4 (84.6 to 91.1)

Sequential therapy||

83.7 (82.7 to 84.7)

87.9

Author disclosure: No relevant financial affiliations.


Copyright © 2021 MD Aware, LLC (theNNT.com). Used with permission.

This series is coordinated by Christopher W. Bunt, MD, AFP assistant medical editor, and the NNT Group.

A collection of Medicine by the Numbers published in AFP is available at https://www.aafp.org/afp/mbtn.

References

show all references

1. Sugano K, Tack J, Kuipers EJ, et al.; faculty members of Kyoto Global Consensus Conference. Kyoto global consensus report on Helicobacter pylori gastritis. Gut. 2015; 64(9):1353–1367....

2. El-Serag HB, Kao JY, Kanwal F, et al. Houston Consensus Conference on testing for Helicobacter pylori infection in the United States [published correction appears in Clin Gastroenterol Hepatol. 2019;17(4):801]. Clin Gastroenterol Hepatol. 2018;16(7):992–1002.e6.

3. Liou JM, Malfertheiner P, Lee YC, et al.; Asian Pacific Alliance on Helicobacter and Microbiota. Screening and eradication of Helicobacter pylori for gastric cancer prevention: the Taipei global consensus. Gut. 2020;69(12):2093–2112.

4. Graham DY. Transitioning of Helicobacter pylori therapy from trial and error to antimicrobial stewardship. Antibiotics (Basel). 2020;9(10):671.

5. Malfertheiner P, Megraud F, O'Morain CA, et al.; European Helicobacter and Microbiota Study Group and Consensus Panel. Management of Helicobacter pylori infection-the Maastricht V/Florence consensus report. Gut. 2017; 66(1):6–30.

6. 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. Gastroenterology. 2021;161(2):495–507.

7. Shin JM, Inatomi N, Munson K, et al. Characterization of a novel potassium-competitive acid blocker of the gastric H,K-ATPase, 1-[5-(2-fluorophenyl)-1-(pyridin-3-ylsulfonyl)-1H-pyrrol-3-yl]-N-methylmethanamine monofumarate (TAK-438). J Pharmacol Exp Ther. 2011;339(2):412–420.

8. Rouse B, Chaimani A, Li T. Network meta-analysis: an introduction for clinicians. Intern Emerg Med. 2017;12(1): 103–111.

9. Mbuagbaw L, Rochwerg B, Jaeschke R, et al. Approaches to interpreting and choosing the best treatments in network meta-analyses. Syst Rev. 2017;6(1):79.

10. Cipriani A, Higgins JPT, Geddes JR, et al. Conceptual and technical challenges in network meta-analysis. Ann Intern Med. 2013;159(2):130–137.

 

 

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