Efficacy and safety of bismuth quadruple therapy containing minocycline and berberine for initial eradication of Helicobacter pylori: A noninferiority, randomized controlled trial

To the Editor: Helicobacter pylori (H. pylori) infection is an infectious disease with a global prevalence rate as high as 50%. Eradication of H. pylori can alleviate gastric mucosal inflammation, promote ulcer healing, and reduce the risk of gastric cancer.[1] However, the increasing prevalence of antibiotic resistance has become a major factor contributing to the decline in H. pylori eradication rates. There is an urgent clinical need to explore new regimens for H. pylori eradication, especially for specific populations (e.g., penicillin-allergic patients). In this study, we focused on a novel combination therapy of berberine and minocycline (a second-generation tetracycline). We conducted a prospective, single-center, noninferiority, randomized controlled trial to compare the efficacy and safety of an MB regimen (minocycline combined with berberine) to those of an AC regimen (amoxicillin combined with clarithromycin) as part of the bismuth-containing quadruple therapy for the initial eradication of H. pylori. This study was approved by the Ethics Committee of Xijing Hospital (No. KY20232384-C-1). Written informed consent was obtained from all the enrolled patients. Participants who were treatment-naïve adults aged 18–70 years with confirmed H. pylori infection were included. Patients with any of the following conditions were excluded: a history of hypersensitivity to any study medications, recent sustained use of acid-suppressing drugs for two weeks before H. pylori testing, or recent administration of antibiotic bismuth preparations either more than three times per week or for a cumulative period of one month during the pretest period. In the study questionnaire, we collected the following data: patient demographics (sex, age, height, weight, education level, marital status, place of origin, ethnicity, etc.), lifestyle information (smoking status, alcohol consumption, dining habits, drinking water source, dental caries, etc.), and medical history (hypertension, coronary heart disease, diabetes, etc.). A 13C-urea breath test (13C-UBT) or 14C-urea breath test (14C-UBT) was performed to confirm H. pylori infection in the absence of these medications. For results falling within the equivocal range, repeated testing was recommended for confirmation. Sample size calculation was based on the following parameters: a presumed H. pylori eradication rate of 85% in the control group, a noninferiority margin (Δ) of 10%, a one-sided α level of 0.05, a statistical power (1 – β) of 90% (i.e., one-sided β = 0.1), and an anticipated dropout and loss-to-follow-up rate of 20%. On the basis of an appropriate formula, a minimum of 274 patients were needed per group, and a total of 548 patients were ultimately enrolled in the study. A total of 548 eligible patients were randomly allocated in a 1:1 ratio using a computer-generated random number sequence to either the AC group (control) or the MB group (experimental). The AC group received amoxicillin 1000 mg, clarithromycin 500 mg, esomeprazole magnesium 40 mg, and colloidal bismuth tartrate 220 mg. The MB group received berberine 500 mg, minocycline 100 mg, esomeprazole magnesium 40 mg, and colloidal bismuth tartrate 220 mg. All treatments were administered twice daily for 14 days. H. pylori status was assessed again 4–6 weeks after treatment completion using 13C-UBT or 14C-UBT. The primary outcome was the H. pylori infection eradication rate. Secondary outcomes included the incidence of adverse events (AEs), patient compliance, and symptom relief rates at both treatment completion and 4 weeks thereafter. Continuous variables are presented as the mean ± standard deviations and were compared using independent-samples t-test. Categorical variables were analyzed with Chi-squared or Fisher’s exact tests. Noninferiority testing was performed on both intention-to-treat (ITT) and per-protocol (PP) populations. Noninferiority was established if the lower limit of the 95% confidence interval (CI) for the difference in eradication rates (MB group rate minus AC group rate) exceeded –10%. A two-sided P-value of <0.05 was considered to indicate statistical significance. The statistical analysis in this study was conducted using IBM SPSS Statistics software, version 26.0 (IBM Corporation, Armonk, New York, USA). A total of 548 eligible patients were included in the ITT analysis, with 18 in the MB group and 25 in the AC group lost-to-follow-up and 11 in the MB group and 9 in the AC group withdrawing from the study. Consequently, 485 patients were included in the PP analysis [Supplementary Figure 1, https://links.lww.com/CM9/C838]. In the ITT population, no statistically significant differences were observed between the two groups in terms of demographic characteristics, lifestyle factors, medical history, or clinical baseline data (P >0.05) [Supplementary Table 1, https://links.lww.com/CM9/C838]. According to the ITT analysis, the eradication rate was 79.9% (219/274) in the MB group vs. 77.4% (212/274) in the AC group. In the PP analysis, the corresponding rates were 89.4% (219/245) and 88.3% (212/240), respectively. No statistically significant differences in eradication rates were observed between the two groups in either analysis set (P >0.05). Noninferiority testing demonstrated that the lower limits of the 95% CI for the between-group difference (MB – AC) were –4.3% in the ITT analysis and –4.5% in the PP analysis, both exceeding the prespecified noninferiority margin of –10%. Thus, the MB regimen was noninferior to the AC regimen. The primary eradication rates of H. pylori infection between the two groups are shown in Table 1. Table 1 - Helicobacter pylori eradication rates in each therapy group. Items Group n/N Eradication rate (%) Eradication rate difference (%) 95% CI χ 2 values P values ITT analysis MB group 219/274 79.90 2.50 –4.3% to 9.4% 1.565 0.667 AC group 212/274 77.40 PP analysis MB group 219/245 89.40 1.10 –4.5% to 6.7% 0.136 0.712 AC group 212/240 88.30 AC group: Amoxicillin–clarithromycin quadruple therapy; CI: Confidence interval; ITT: Intention-to-treat; MB group: Minocycline–berberine quadruple therapy; PP: Per-protocol. Potential factors influencing H. pylori eradication rates were assessed within the PP population. In both the MB and AC groups, eradication success was not significantly associated with age, sex, body mass index (BMI), nationality, geographic origin, marital status, level of education, smoking, drinking, drinking water source, decayed teeth, dining practices, long-term pharmacotherapy, family history, or chronic medical history (all P values >0.05) [Supplementary Table 2, https://links.lww.com/CM9/C838]. The incidence of AEs, medication compliance, and symptom improvement rates are detailed in Supplementary Tables 3 and 4, https://links.lww.com/CM9/C838. The overall incidence of AEs was 27.7% in the MB group and 27.0% in the AC group, with no statistically significant difference (P >0.05). The reported AEs included bitterness, diarrhea, nausea, vomiting, dizziness, abdominal pain, abdominal distension, poor appetite, and rash, which were all mild-to-moderate in severity and self-limited. The incidence of bitterness was significantly higher in the AC group (13.9% vs. 2.6%, P <0.001), whereas dizziness (9.9% vs. 2.2%, P <0.001) and nausea (13.5% vs. 5.1%, P = 0.001) were more frequent in the MB group. Nausea and dizziness are attributable to the known AEs of minocycline, whereas bitterness is associated with the pharmacological properties of clarithromycin. Furthermore, patient compliance and clinical symptom improvement rates were comparable between the two groups, with no statistically significant differences (P >0.05). The 2022 Chinese Treatment Guidelines recommend combinations of five antibiotics, namely (1) amoxicillin, (2) clarithromycin, (3) levofloxacin, (4) metronidazole, and (5) tetracycline for the initial treatment of H. pylori.[1] Studies have demonstrated that the resistance rates of H. pylori to clarithromycin, metronidazole, and levofloxacin are greater than 15%; therefore, these three antibiotics may no longer be suitable for the eradication treatment of H. pylori. In addition, although H. pylori has a low resistance rate to amoxicillin, tetracycline, and furazolidone, there are still issues to resolve, such as amoxicillin allergy, difficulty in obtaining medications, and poor tolerance. Minocycline, a second-generation semisynthetic tetracycline derivative, exhibits potent bactericidal activity with a ribosomal affinity 20 times greater and an in vitro translation inhibition efficiency 2–7 times greater than that of tetracycline. A meta-analysis of minocycline clinical trials has demonstrated its safety and efficacy for H. pylori eradication.[2] Berberine, an isoquinoline alkaloid initially extracted from the traditional Chinese plant—Coptis chinensis (Huang Lian), has been shown to have diverse pharmacological effects in several studies, such as anti-inflammatory, anticancer, antiulcer, antibacterial, and immunopotentiation effects. Studies have demonstrated that berberine primarily exerts its inhibitory effects on H. pylori proliferation by suppressing the enzymatic activities of arylamine N-acetyltransferase and urease.[3] On the basis of a series of previous randomized controlled trials conducted by our group, berberine has been demonstrated to be an effective, safe, cost-effective, and clinically accessible agent for H. pylori eradication.[4] Building on earlier research, the efficacy and safety of MB for the primary eradication of H. pylori infection were explored in our study. We report a noninferior efficacy of bismuth quadruple therapy containing minocycline and berberine to that of a regimen containing amoxicillin and clarithromycin for the initial eradication of H. pylori, along with favorable compliance and safety profiles. Our study has several limitations. First, it was a single-center design, which may lead to geographical bias. Second, the resistance rates to clarithromycin in the control group were relatively high in China. Third, we used only one method to confirm H. pylori infection. Despite these limitations, our study establishes a role for bismuth quadruple therapy containing minocycline and berberine as an effective and validated alternative option for H. pylori-infected patients, especially for specific populations such as penicillin-allergic patients. Funding This work was supported by the Noncommunicable Chronic Diseases–National Science and Technology Major Project (No. 2025ZD0545301). Conflicts of interest None.