Eradication of Helicobacter pylori With Vonoprazan-Amoxicillin Dual Therapy as an Alternative for Bismuth-Based Quadruple Therapy: A Systematic Review and Noninferiority Meta-Analysis
Abstract
Introduction: Whether the efficacy of vonoprazan-amoxicillin dual therapy (VADT) for Helicobacter pylori eradication is clinically acceptable compared with guideline-recommended bismuth-based quadruple therapy (BQT) remains uncertain. Prior analyses have largely relied on superiority frameworks.
Methods: PubMed, EMBASE, and CENTRAL were searched through December 23, 2025, for randomized controlled trials (RCTs) comparing VADT with BQT for H. pylori eradication. Intention-to-treat and per-protocol eradication were summarized through Bayesian meta-analysis as absolute risk differences. Noninferiority margins were prespecified at -10%, -5%, and 0% (superiority). Adverse events (AEs) were evaluated as secondary outcomes. Evidence certainty was assessed using GRADE.
Results: Eighteen Asian RCTs (5866 participants) were included. In intention-to-treat analyses, VADT achieved an absolute eradication increase of +2.27% compared with BQT (95% credible interval [CrI] -1.34% to +5.71%). The posterior probability of noninferiority exceeded 99% for the -10% and -5% margins but declined to 90.41% at 0%. In per-protocol analyses, eradication showed an absolute decrease of 0.28% (95% CrI -3.30% to +4.17%), with noninferiority probabilities exceeding 99% for the -10% and -5% margins, but declining to 56.43% at 0%. VADT was associated with significantly lower rates of dysgeusia, dizziness/headache, nausea/vomiting, and overall mild AEs. Evidence certainty was moderate for intention-to-treat…
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Evidence Hub reads this as a meta-analysis, done in people. Its evidence level is 1 of 5 (Highest · pooled evidence). Pooled evidence from several studies sits at the top of the evidence pyramid. Reported size: 5,866 participants or records.
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