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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 Apr 8. pii: S0016-5085(21)00632-6. doi: 10.1053/j.gastro.2021.04.012. (Systematic review)

BACKGROUND & AIMS: A number of double, triple, and quadruple therapies have been proposed as first-line empiric treatments for Helicobacter pylori infection. However, knowledge of their worldwide and regional comparative efficacy is lacking. We examined the comparative effectiveness of all empirically used first-line regimens tested against standard triple treatment using a network meta-analysis of published randomized controlled trials.

METHODS: Data extracted from eligible randomized controlled trials were entered into a Bayesian network meta-analysis to investigate the comparative efficacy of H pylori infection empiric first-line regimens and to explore their effectiveness rank order. The ranking probability for each regimen was evaluated by means of surfaces under cumulative ranking values.

RESULTS: Sixty-eight eligible randomized controlled trials were included, giving a total of 92 paired comparisons with 22,975 patients randomized to 8 first-line regimens. The overall results showed that only vonoprazan triple therapy and reverse hybrid therapy achieved cure rates of >90%. Levofloxacin triple therapy performed best in Western countries (eradication rate 88.5%). The comparative effectiveness ranking showed that vonoprazan triple therapy had the best results, whereas standard triple therapy was the least efficacious regimen (surfaces under cumulative ranking 92.4% vs 4.7% respectively; odds ratio, 3.80; 95% credible interval, 1.62-8.94).

CONCLUSIONS: For first-line empiric treatment of H pylori infection, vonoprazan triple therapy and reverse hybrid therapy achieved high eradication rates of >90%. Levofloxacin triple therapy achieved the highest eradication rates in Western countries. Standard triple therapy was the least efficacious regimen in this network meta-analysis.

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Discipline Area Score
Family Medicine (FM)/General Practice (GP) 6 / 7
General Internal Medicine-Primary Care(US) 6 / 7
Gastroenterology 6 / 7
Internal Medicine 5 / 7
Comments from MORE raters

Gastroenterology rater

Very useful structure comparison among regimens. There will be some regional variation, but this is useful information and points to novel regimens as being optimal.

Gastroenterology rater

This was not an easy paper to read. Nonetheless, such periodic assessments are probably necessary, but the real issue is probably antibiotic resistance, which will be an on-going problem. In fact, it is likely that much of the data are already out-of-date for that reason. It should also be remembered that the indirect comparisons assume that the group(s) receiving the common intervention are all equivalent, even though that is likely not to be the case. So, accepting these numbers at face value also requires a certain amount of faith.
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