Cost-effectiveness of first-line regimens for Helicobacter pylori infection in the United States

Introduction: Helicobacter pylori (H. pylori) infection remains a significant global health burden. The 2024 American College of Gastroenterology (ACG) guideline recommended bismuth quadruple therapy (BQT) as the first-line treatment for treatment-naive patients. This study aimed to assess the cost-effectiveness of five regimens from a US healthcare payer perspective. Methods: A Markov model was employed to evaluate five H. pylori eradication regimens: (1) clarithromycin triple therapy, (2) vonoprazan dual therapy, (3) vonoprazan triple therapy, (4) rifabutin triple therapy, and (5) BQT. We simulated a hypothetical cohort of treatment-naïve adults with H. pylori over 1-, 10-, 20-year and lifetime horizons. Model outcomes were measured in incremental cost-effectiveness ratios (ICERs) and net monetary benefit (NMB) at willingness-to-pay (WTP) thresholds of $100,000 and $150,000/QALY. Deterministic and probabilistic sensitivity analysis (PSA) were performed to assess model robustness. Results: BQT had the lowest lifetime cost per patient ($ 193,651) and was used as the reference. Rifabutin and vonoprazan triple therapies had ICERs of $45,971 and $290,572 per QALY gained, respectively. Clarithromycin triple and vonoprazan dual therapies were dominated by BQT. Rifabutin triple therapy had the highest NMB, followed by BQT. Scenario analysis confirmed that rifabutin triple therapy maintained the highest NMB over 10- and 20-year horizons. Sensitivity analyses identified eradication rates of BQT were among the most influential parameters. PSA showed rifabutin triple therapy had the highest probability of being cost-effective at both WTP thresholds, followed by BQT. Conclusion: BQT was found to be the cost-effective first-line treatment. Rifabutin triple therapy was a cost-effective alternative. Policymakers should prioritize BQT and rifabutin triple therapy versus other therapies.