Evaluating vonoprazan bismuth‐containing triple therapy versus quadruple therapy for Helicobacter pylori

After a careful analysis of the study by Liang et al., we endorse their conclusion that a triple therapy regimen containing vonoprazan (vonoprazan + amoxicillin + a bismuth agent) in patients with an initial infection of Helicobacter pylori shows a similar H. pylori eradication rate compared to the traditional quadruple therapy (esomeprazole + clarithromycin + amoxicillin + a bismuth agent), with fewer side effects and lower treatment costs.1 However, we believe there are several key issues in the study that may affect the accuracy and interpretation of the results. Firstly, the study does not clearly indicate whether patients who had undergone esophageal resection or gastric surgery (including bariatric surgery) were excluded.2 In clinical studies of H. pylori eradication therapy, these patients are usually excluded because such surgeries can lead to significant changes in the structure and function of the digestive tract, which may affect the metabolism and absorption of drugs. Altered gastrointestinal transit post-surgery can change the concentration and contact time of drugs on the gastric mucosa.3 Additionally, surgery might alter the pattern of gastric acid secretion, thereby affecting the efficacy of antibiotics and acid-suppressing medications. If these special cases were not excluded, it could bias the assessment of treatment efficacy. Secondly, the study did not record the specific duration of H. pylori infection, the status of H. pylori infection in the patient's family, family history of gastric cancer, or the participants' antibiotic use in the past 2 years.4 The duration of infection can affect the treatment response to H. pylori, as long-term infections may lead to bacterial resistance to antibiotics or cause deeper changes in the gastric mucosa, affecting treatment outcomes. Information about H. pylori infection in the family and family history of gastric cancer can provide important insights into susceptibility and genetic factors, while the history of antibiotic use is crucial for assessing patients' resistance patterns and selecting effective treatment strategies. The absence of this information may limit the study's comprehensive assessment and applicability of treatment strategies. Lastly, the study did not assess the impact of host genetic polymorphisms, particularly CYP2C19 polymorphism.5 CYP2C19 gene polymorphisms significantly affect drug metabolism, especially the metabolism of proton pump inhibitors (PPIs), which are commonly used in H. pylori treatment.6 Individuals with different genotypes vary in their drug metabolism rates, which can lead to significant differences in drug efficacy and side effects among patients. Future studies should consider including assessments of host genetic polymorphism to enhance the accuracy and clinical relevance of the results. In summary, although the study by Liang et al. provides valuable insights, these issues must be addressed to further improve the scientific rigor and credibility of the conclusions. There are no individuals or groups to thank for this study.