Vonoprazan-bismuth triple therapy eradicates H. pylori in up to 90.9% vs. standard care
Click Here to Manage Email Alerts
Key takeaways:
- A vonoprazan-amoxicillin-bismuth triple therapy achieved an H. pylori eradication rate similar to that of the standard quadruple therapy.
- Fewer adverse events were reported with triple vs. quadruple therapy.
A triple therapy of vonoprazan, amoxicillin and bismuth potassium citrate achieved an eradication rate of just over 90%, similar to that of the standard quadruple therapy, in patients with Helicobacter pylori infection, according to data.
“Eradication of H. pylori infection is necessary for the management of gastrointestinal disorders,” Jing Wen Liang, of the department of gastroenterology and hepatology at Tongji Hospital in China, and colleagues wrote in the Journal of Gastroenterology and Hepatology. “The primary treatment options are quadruple therapy or a combination of a proton pump inhibitor, bismuth or two antibiotics.
“However, the growing prevalence of H. pylori strains resistant to antibiotics and adverse effects associated with prolonged use of broad-spectrum antibiotics have made it progressively difficult to eradicate the pathogen.”
In a multicenter, randomized controlled trial, Liang and colleagues investigated the efficacy of vonoprazan, amoxicillin and bismuth triple therapy vs. China’s standard first-line quadruple therapy among 597 treatment-naïve adult patients with H. pylori infection.
Patients were randomly assigned to 14 days of vonoprazan (20 mg twice daily), amoxicillin (750 mg three times daily) and bismuth potassium citrate (600 mg with bismuth 220 mg twice daily) or esomeprazole (20 mg twice daily), clarithromycin (500 mg twice daily), amoxicillin (1 g twice daily) and bismuth potassium citrate (600 mg with bismuth 220 mg twice daily). Baseline characteristics between groups were similar.
According to intention-to-treat analysis, which included 300 patients on triple therapy and 297 on quadruple therapy, the eradication rates were 83.7% and 83.2%, respectively (HR = 0.994; 95% CI, 0.925-1.068). In the per-protocol analysis, which excluded 50 patients for incomplete follow-up or treatment discontinuation, the rates were 90.9% and 89.7% (HR = 0.986; 95% CI, 0.933-1.042).
The researchers reported that “bitter mouth” was the most common adverse event, which was more prevalent among patients who received quadruple vs. triple therapy (16.2% vs. 3.7%). Additional adverse reactions included nausea, vomiting, upper abdominal pain and fullness, allergy, constipation and diarrhea, none of which reached statistically significant differences between the groups.
“The study results suggest that the potent acid inhibition attained by the vonoprazan 20 mg BID can eradicate H. pylori with TID dosing of amoxicillin and bismuth potassium citrate,” Liang and colleagues wrote. “The important factors related to eradication success include sensitive antibiotics, good compliance and high intragastric pH.”
They continued: “Compared with PPIs, vonoprazan has a faster, stronger and longer duration of acid inhibition in clinical trials, potentially explaining the increase in H. pylori eradication.”
Perspective
Back to Top
Yi Qin, MD
Vonoprazan is a potassium-competitive acid blocker that has gained significant attention in recent years due to its unique pharmacological characteristics, which differentiate it from PPIs.
Unlike PPIs, which need an acidic environment for activation but also degrade quickly in acid, vonoprazan is stable and active at all pH levels. This means that vonoprazan does not require an empty stomach for administration, has a faster onset of action and a prolonged duration of effect, providing sustained acid suppression.
This unique characteristic of vonoprazan is important in the treatment of H. pylori. In today’s world, with increasing antibiotic resistance, a higher intragastric pH increases the susceptibility of H. pylori to antibiotics. In multiple global populations, vonoprazan-based therapies have been shown to be noninferior, if not superior, to PPI-based therapies in the eradication of H. pylori.
This study found the rates of eradication were excellent and similar in both groups, but with less than half the cost in the group with vonoprazan, which also experienced fewer side effects such as “bitter taste.” Although seemingly trivial, the lower cost and incidence of side effects with vonoprazan may significantly improve patient adherence to therapy, which is crucial for successful eradication of H. pylori.
Although these study results are promising, it is important to note that vonoprazan is new in the U.S. and currently costs significantly more than generic PPI medications. In addition, clarithromycin is no longer commonly used due to increased clarithromycin resistance. However, standard quadruple therapy consists of other antibiotics such as metronidazole and tetracycline/doxycycline, which also have side effects that limit patient adherence.
Although the decreased costs of vonoprazan are not presently generalizable in the U.S., simplifying the H. pylori regimen is still a transformative advancement.
Collapse
Read more about
Click Here to Manage Email Alerts