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Introduction: The declining efficacy of standard triple therapy for Helicobacter pylori (H. pylori) eradication, largely driven by increasing antibiotic resistance, has highlighted the need for alternative treatment strategies. Vonoprazan-amoxicillin dual therapy (VDT) has emerged as a promising regimen due to the potent and sustained acid suppression provided by vonoprazan. This meta-analysis aims to compare the efficacy and safety of VDT versus clarithromycin-based standard triple therapy (STT) for H. pylori eradication in adults. Methods: A systematic search of PubMed, Scopus, and the Cochrane Library was conducted from inception to 15 March 2026 for randomized controlled trials (RCTs) comparing VDT (vonoprazan plus amoxicillin) with STT (proton pump inhibitor, amoxicillin, and clarithromycin) for H. pylori eradication (PROSPERO "CRD420261357715"). Heterogeneity was assessed using the I2 statistic and Cochran's Q test. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using the Mantel-Haenszel method within a restricted maximum-likelihood random-effects model. Results: Five RCTs were included with 1363 patients (VDT: 680, STT: 683). VDT demonstrated a significantly higher H. pylori eradication rate compared with STT (RR 1.17; 95% CI [1.07; 1.27]; p = 0.007; I2 = 11%). Conclusions: This meta-analysis suggests that VDT may be associated with higher H. pylori eradication rates than clarithromycin-based STT. Further large, well-designed RCTs are needed before firm first-line recommendations can be made.

Abstract licence: CC BY

Since the 2020 Korean guidelines for Helicobacter pylori treatment, clarithromycin resistance rates have risen from 17.8% to 33.3%, dual-priming oligonucleotide-based polymerase chain reaction-guided tailored therapy has been adopted, and potassium-competitive acid blockers (P-CABs) have become available. This fourth revision addressed these changes. Nine key questions were addressed through systematic review and meta-analysis. Thirteen recommendations were evaluated using a modified Delphi process involving 64 experts. Twelve recommendations achieved a first-round consensus; one required revision and achieved 73.9% agreement. Key changes included: 1) a dual-pillar strategy of tailored therapy and empirical quadruple therapy; 2) restricted use of empirical clarithromycin-based triple therapy under specific conditions; 3) removal of sequential therapy; 4) use of P-CABs as alternatives to proton pump inhibitors; 5) expansion of eradication indications to include gastric cancer prevention in H. pylori gastritis and regression of hyperplastic polyps ≤10 mm; and 6) positioning of bismuth quadruple therapy as a conditionally recommended first-line empirical option, with preference for reservation as salvage therapy, and introduction of modified bismuth quadruple therapy (addition of bismuth to conventional regimens) as an additional first-line empirical option. The revised guidelines provide updated evidence-based recommendations for the diagnosis and treatment of H. pylori infection, reflecting the rapidly changing antibiotic resistance landscape and the introduction of new diagnostic and therapeutic tools in Korea. These guidelines aim to assist clinicians, patients, policymakers, and medical educators in optimizing H. pylori management. They may differ from the current medical insurance standards and will be further revised based on emerging evidence.

Abstract licence: CC BY-NC