Vonoprazan-amoxicillin a good alternative to B-quadruple therapy for H pylori eradication

Dual therapy with vonoprazan and amoxicillin (VA-dual) for 10 days results in a 90.8-percent eradication rate of Helicobacter pylori (H pylori) and fewer adverse events (AEs) compared with the standard 14-day bismuth-based quadruple therapy (B-quadruple), a study has shown.

“VA-dual is a promising cost-effective regimen and worth generalization in population-based H pylori screening and eradication strategy,” said the researchers, led by Tian-Lian Yan, Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.

Yan and colleagues conducted this prospective randomized clinical trial at three institutions in China to compare the eradication rate, AEs, and compliance of 10-day VA-dual regimen with the standard 14-day B-quadruple regimen as first-line H pylori treatment.

The research team randomized 314 treatment-naive, H pylori–infected patients in a 1:1 ratio to receive either 10-day VA-dual regimen or 14-day B-quadruple therapy. A ¹³C-urea breath test at least 4 weeks after treatment was performed to determine eradication success.

In intention-to-treat (ITT) analysis, the eradication rates were 86.0 percent with VA-dual and 89.2 percent with B-quadruple (p=0.389), while those in modified ITT analysis were 88.2 percent and 91.5 percent (p=0.338), respectively. The corresponding eradication rates in per-protocol analysis were 90.8 percent and 91.3 percent (p=0.884). [Am J Gastroenterol 2024;119:655-661]

“The efficacy of the VA-dual remained noninferior to B-quadruple therapy in all ITT, modified ITT, and per-protocol analyses,” Yan said.

AE incidence was significantly lower in the VA-dual group than in the B-quadruple group (p<0.001). Notably, poor compliance was the main reason for eradication failure in the VA-dual (p<0.001), but not in the B-quadruple group (p=0.110).

“It is noteworthy that poor compliance (treatment duration <8 days) was significantly associated with eradication failure in the VA-dual group, while not in the B-quadruple group, indicating a possible just right course for VA-dual of 10 days, but a redundant course for B-quadruple for 14 days,” Yan said.

Cost-effectiveness

“The 10-day VA-dual therapy as first-line treatment has shown remarkable benefits, compared with 14-day B-quadruple therapy,” according to Yan and colleagues. “First, the cost-effectiveness of H pylori regimens is a crucial consideration for promoting population-based H pylori screening and eradication strategy in China.”

For instance, the cost of 10-day VA-dual regimen was 216.54 RMB per patient (29.7 USD), while that of 14-day B-quadruple therapy was 389.42 RMB per patient (53.5 USD), resulting in a 44-percent expense reduction in each patient.

Second, amoxicillin delivers certain benefits such as availability, rare resistance, nearly no secondary resistance, few side effects, and low impact on the intestinal flora. [Front Cell Infect Microbiol 2022;12:881968]

“Therefore, antimicrobial susceptibility testing is not necessary before VA-dual therapy, and even if the eradication fails, future antibiotic would still face wide selection,” Yan said.

“The stronger and more sustained acid inhibitory effect enhances antibiotic function by decreasing the minimal inhibitory concentration, increasing the chemical stability, and increasing the concentration of antibiotics in succus gastricus,” according to the researchers. [Intern Med 2020;59:153-161; Aliment Pharmacol Ther 2023;58:16-25]