Hideki Mori, Hidekazu Suzuki
Helicobacter pylori infection-although its overall prevalence has declined over time-remains a major cause of peptic ulcer disease and gastric cancer, particularly among older adults in aging societies such as Japan. While eradication therapy is known to reduce the gastric cancer risk, its use in older adults is often complicated by comorbidities, polypharmacy, altered drug metabolism, and limited life expectancy. This review summarizes current perspectives on the management of H. pylori infection in older patients, based on Japanese clinical practice and recent evidence. Older individuals frequently have long-standing infections accompanied by advanced gastric atrophy and intestinal metaplasia, which may adversely affect diagnostic accuracy and therapeutic outcomes. Diagnostic evaluation is further complicated by severe mucosal atrophy and the frequent use of acid-suppressive medications, requiring careful interpretation of test results and, in some cases, correlation with endoscopic findings. In Japan, vonoprazan-based eradication regimens have become the standard of care because of their high efficacy and pharmacological stability regardless of CYP2C19 genotype. Available data indicate that eradication therapy is generally safe and well tolerated in older patients, with adverse event rates comparable to those observed in younger populations. Eradication therapy is highly recommended for disease-specific indications (e.g., peptic ulcer) and for primary prevention of gastric cancer. Overall, older age alone should not be considered a contraindication to eradication therapy; rather, treatment decisions should be based on a comprehensive assessment of comorbidities, concomitant medications, the patient's functional status, and the patient's preferences.