Can Helicobacter pylori (H. pylori) infection cause hyperacidity and flatulence, and is adding Vonoprazan (Vonoprazan) a suitable approach?

From the Guidelines

Hyperacidity and flatulence may indeed be related to Helicobacter pylori infection, and the recommended approach is to test for H. pylori before initiating treatment, with vonoprazan being a viable alternative to traditional PPIs in eradication regimens, particularly in areas with high clarithromycin resistance, as evidenced by a study published in Gastroenterology in 2019 1. The use of vonoprazan, a potassium-competitive acid blocker, has shown promising results in H. pylori eradication, with higher eradication rates compared to traditional PPI-based therapy, especially in clarithromycin-resistant strains 1. Some key points to consider in the approach to hyperacidity and flatulence potentially caused by H. pylori infection include:

• Testing for H. pylori before initiating treatment
• Considering vonoprazan as an alternative to traditional PPIs in eradication regimens, particularly in areas with high clarithromycin resistance
• Using vonoprazan-based triple therapy, which includes vonoprazan 20mg, amoxicillin 1g, and clarithromycin 500mg, all twice daily for 7-14 days
• Implementing lifestyle modifications, such as avoiding trigger foods, eating smaller meals, limiting alcohol and caffeine, and maintaining a healthy weight, to address both the infectious cause and symptomatic relief of hyperacidity and flatulence. The potent acid suppressive effect of vonoprazan improves amoxicillin effectiveness, and its use may obviate the need for clarithromycin in some cases, thereby reducing the antimicrobial burden on society 1. Overall, the approach to hyperacidity and flatulence potentially caused by H. pylori infection should prioritize testing, consider the use of vonoprazan in eradication regimens, and incorporate lifestyle modifications to address both the infectious cause and symptomatic relief.

From the FDA Drug Label

Treatment of H pylori Infection Use of VOQUEZNA is not recommended for the treatment of H. pylori infection in patients with severe renal impairment (eGFR < 30 mL/min) [see Dosage and Administration (2.2) and Clinical Pharmacology (12.3)]. Treatment of H pylori Infection Use of VOQUEZNA is not recommended for the treatment of H. pylori infection in patients with moderate to severe hepatic impairment (Child-Pugh Class B and C) [see Dosage and Administration (2.3) and Clinical Pharmacology (12. 3)].

The approach to treating H. pylori infection with vonoprazan should consider the patient's renal and hepatic function.

• Severe renal impairment (eGFR < 30 mL/min): Vonoprazan is not recommended for the treatment of H. pylori infection.
• Moderate to severe hepatic impairment (Child-Pugh Class B and C): Vonoprazan is not recommended for the treatment of H. pylori infection. For patients with hyperacidity and flatulence suspected to be caused by H. pylori infection, the use of vonoprazan may be considered if the patient's renal and hepatic function are within normal limits or mildly impaired. However, the decision to add vonoprazan should be made with caution and under the guidance of a healthcare professional, considering the potential risks and benefits. 2 2

From the Research

Hyperacidity and Flatulence due to H. pylori Infection

• Hyperacidity and flatulence may be symptoms of H. pylori infection, which can lead to gastritis, gastric and duodenal ulcers, and gastric cancer 3.
• The goal of therapy is complete eradication of the infection.

Approach to H. pylori Eradication

• First-line therapy for H. pylori infection includes clarithromycin triple therapy, bismuth quadruple therapy, or concomitant therapy 3.
• Alternative therapies, such as high-dose amoxicillin-proton pump inhibitor (PPI) dual therapy, have shown promise in eradicating H. pylori infection 4.
• Vonoprazan, a potassium-competitive acid blocker, has been evaluated as a potential treatment for H. pylori infection, with results showing noninferiority to standard treatment in nonresistant strains and superiority in clarithromycin-resistant infections 5.

Adding Vonoprazan to H. pylori Treatment

• Vonoprazan triple and dual therapy have been shown to be effective in eradicating H. pylori infection, with eradication rates of 84.7% and 78.5%, respectively 5.
• Vonoprazan-based regimens were superior to proton pump inhibitor-based triple therapy in clarithromycin-resistant strains and in the overall study population 5.
• The use of vonoprazan in combination with amoxicillin and/or clarithromycin may be a viable option for patients with H. pylori infection, particularly those with clarithromycin-resistant strains 5.