Potassium-competitive acid blockers for Helicobacter pylori eradication in pediatrics: a narrative review of pharmacologic rationale, clinical evidence, and practical considerations.
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Helicobacter pylori (H. pylori) infection remains highly prevalent worldwide and is strongly associated with chronic gastritis, peptic ulcer disease, and an elevated risk of gastric cancer. In pediatric clinical practice, eradication therapy is challenged by rising antibiotic resistance, inadequate acid suppression, and poor adherence to complex multidrug regimens. Potassium-competitive acid blockers (P-CABs) represent a newer class of antisecretory agents that competitively and reversibly inhibit gastric H+/K+-ATPase, resulting in a more rapid onset and more sustained control of intragastric pH compared with conventional proton pump inhibitors (PPIs). P-CABs offer greater flexibility in dosing timing relative to meals in children, with substantial potential to simplify treatment regimens and improve H. pylori eradication rates in the pediatric population. This narrative review summarizes the pharmacologic rationale for using P-CABs in pediatric H. pylori eradication, synthesizes current clinical evidence-derived mainly from Japanese observational studies of vonoprazan (VPZ)-and discusses key issues regarding resistance, tolerability, and practical clinical application. Published pediatric studies, predominantly involving adolescents and older pediatric cohorts, suggest that VPZ-based regimens may achieve favorable eradication rates, while short-term tolerability appears broadly similar to that of PPI-based therapies in the available comparative data. However, the existing evidence is limited by small sample sizes, narrow geographic scope, and marked heterogeneity in study design, antibiotic backbones, and resistance patterns, which preclude direct cross-study comparisons. Data supporting other P-CABs in pediatric populations remain very scarce. Future research should prioritize pediatric pharmacokinetic/pharmacodynamic studies to optimize weight- and age-based dosing, conduct resistance-stratified comparative trials, and perform cost-effectiveness analyses. Until more robust pediatric evidence becomes available, P-CAB-based regimens may be considered a viable option in selected clinical scenarios, while clinicians should exercise caution when extrapolating adult data and remain vigilant toward local antibiotic resistance epidemiology.