NEW evidence from a comprehensive systematic review and network meta-analysis suggests that simpler dual therapy regimens may be as effective as more complex antibiotic combinations for first-line Helicobacter pylori eradication, while offering advantages in safety and patient compliance.
As rising antibiotic resistance continues to complicate H. pylori management worldwide, identifying treatment strategies that balance efficacy with tolerability remains a clinical priority. To address this, researchers conducted a systematic review and network meta-analysis of randomised controlled trials comparing dual, triple, and quadruple first-line eradication regimens.
Comparing First-Line Treatment Strategies
The analysis included 56 randomised controlled trials published in English and identified through searches of PubMed, the Cochrane Library, ProQuest, and Scopus up to October 12, 2025. Trials were eligible if they reported eradication rates, adverse events, and compliance for dual therapy compared with triple or quadruple regimens.
Dual therapy demonstrated eradication rates comparable to triple therapy in both intention-to-treat and per-protocol analyses, with no statistically significant differences observed. These findings challenge the assumption that more drugs necessarily lead to better eradication outcomes in first-line treatment.
Fewer Side Effects, Better Adherence
When compared with quadruple therapy, dual therapy showed superior performance. Patients receiving dual therapy had significantly higher eradication rates, substantially fewer adverse events, and better treatment compliance. The lower burden of side effects is particularly notable, as gastrointestinal intolerance and complex dosing schedules are common reasons for poor adherence in H. pylori treatment.
Higher compliance rates with dual therapy may help explain its favourable outcomes, reinforcing the importance of treatment simplicity in real-world effectiveness.
Insights From Network Meta-Analysis
Using network meta-analysis to rank treatment strategies, the authors found that triple therapy retained the highest overall probability of being the most effective first-line option, followed by quadruple therapy. However, a specific dual therapy regimen, referred to as RAC-7, achieved the highest probability of effectiveness in both intention-to-treat and per-protocol analyses.
These findings suggest that while traditional regimens remain highly effective, selected dual therapies may offer an optimal balance between efficacy, safety, and adherence.
Implications for Clinical Practice
The authors conclude that dual therapy represents a promising first-line option for H. pylori eradication, particularly in settings where treatment tolerability and adherence are key concerns. However, they caution that most included trials were conducted in Asian populations, highlighting the need for further studies in non-Asian cohorts.
They also emphasise the importance of resistance-guided treatment strategies to refine eradication approaches globally. As antibiotic resistance patterns continue to evolve, flexible and patient-friendly regimens may play an increasingly important role in H. pylori management.
Reference
Taufiqqurrachman I et al. Comparative efficacy, safety and compliance with dual, triple and quadruple therapy as the first-line treatment regimens for Helicobacter pylori eradication: a systematic review and network meta-analysis. BMJ Open Gastroenterology. 2026;13:e002037037
