Vonoprazan Quadruple Therapy Improves H. pylori Eradication

A prospective, randomized, open-label trial published in The Egyptian Journal of Internal Medicine found higher Helicobacter pylori eradication with vonoprazan-based bismuth quadruple therapy than with a rabeprazole-based regimen in treatment-naive patients in Egypt. The study ran from September 2025 to February 2026.

Investigators enrolled 320 patients with confirmed H. pylori infection and randomly assigned 160 patients to each group. Both groups received bismuth, metronidazole, and tetracycline for 10 days; acid suppression was provided by either vonoprazan 20mg twice daily or rabeprazole 20mg twice daily. Eradication was assessed by stool antigen enzyme-linked immunosorbent assay four weeks after therapy. The trial is registered at ClinicalTrials.gov (NCT07165444). In the intention-to-treat analysis, eradication occurred in 143 of 160 patients (89.38%) with the potassium-competitive acid blocker (P-CAB) regimen and 121 of 160 (75.63%) with the proton pump inhibitor (PPI) regimen. The risk ratio was 1.18 (95% CI, 1.07-1.31; P=0.001), with an absolute difference of 13.75 percentage points.

Recorded adverse drug reactions did not differ significantly between groups. Adequate adherence, defined as taking at least 80% of prescribed doses, was observed in 96.88% of P-CAB recipients and 91.88% of PPI recipients (P=0.086). Patient satisfaction distributions differed (P=0.049), although investigators cautioned that a nonvalidated five-point scale and no prespecified clinically important threshold limited interpretation.

Interpretation is further limited by the open-label, single-center design, lack of susceptibility testing, absence of a separate per-protocol analysis, outcome confirmation only by stool antigen testing, and adherence measurement using pill counts and self-report. The authors said larger multicenter trials incorporating regional resistance patterns and extended follow-up are needed to confirm comparative effectiveness.

Source: Flefel MG, Sarhan ME, Aboismail AAM, et al. Potassium-competitive acid blocker versus proton pump inhibitor as a part of bismuth-based quadruple therapy for treatment of Helicobacter pylori infection: a randomized controlled trial. Egypt J Intern Med. 2026;38:142. doi:10.1186/s43162-026-00727-7