S2129 H. pylori Therapy: Susceptibility-Based Proton Pump Inhibitor Triple Therapy Is Less Expensive and More Effective Than Empiric Vonoprazan Triple Therapy

Introduction: Helicobacter pylori susceptibility testing has become universally available in the U.S. and susceptibility-based therapy has been proven to reliably yield high cure rates. However. clarithromycin resistance continues to increase resulting in generally poor cure rates with empiric proton pump inhibitor (PPI)-based clarithromycin triple therapy. Nonetheless, both the American College of Gastroenterology guideline and American Gastroenterological Association H. pylori treatment recommendations recommend empiric vonoprazan clarithromycin triple especially for treatment naïve patients. Methods: We modeled the costs and cure rates of empiric vonoprazan clarithromycin triple therapy from U.S. clinical trial data to compare the cost and cure rates for tailored PPI triple therapy. We included costs for antibiotic susceptibility testing via next-generation sequencing (NGS) of stool or a paraffin-embedded gastric biopsy. Medication costs were estimated using retail prices. NGS costs were estimated using American Laboratories pricing. The suggested retail price for vonoprazan clarithromycin triple therapy is ∼$1,000. The costs for generic esomeprazole-clarithromycin triple therapy is ∼$50. The cash price for NGS molecular susceptibility testing of a stool or previously obtained gastric biopsy is ∼$500. Mayo charges $465 for stool clarithromycin testing. Results: The price of empiric vonoprazan-clarithromycin triple therapy is approximately twice that of equally or more effective, susceptibility-based tailored PPI-containing triple therapy (e.g., $1,000 vs $550). NGS susceptibility testing provides data regarding susceptibility to all available antibiotics (e.g., provides more treatment options). In addition to increased cost, data from the U.S. vonoprazan trial showed >90% of those receiving vonoprazan triple therapy obtained no antimicrobial benefits from the clarithromycin received.1 Conclusion: Susceptibility-based PPI triple therapy provides equal or higher cure rates than empiric vonoprazan triple therapy, is markedly less expensive, and avoids the administration of unneeded clarithromycin that accompanies empiric vonoprazan triple therapy.1 When vonoprazan-amoxicillin dual therapy is optimized to reliably produce cure rates >90% it would be an effective but very expensive empiric treatment option. Reference 1. Graham DY. Crises in antimicrobial stewardship: Misuse of clarithromycin for Helicobacter pylori therapy. Pharmacoepidemiology 2024;3:82â93.