The comparative efficacy and safety of 9 traditional Chinese medicines combined with standard quadruple therapy for Helicobacter pylori-associated gastritis: a systematic review and network meta-analysis

BACKGROUND: There are 9 traditional Chinese medicines (TCMs) combined with standard quadruple (SQ) available for the treatment of Helicobacter pylori (Hp)-associated gastritis, but their relative efficacy and best options in clinical decision making are unknown due to a lack of high-quality head-to-head randomized controlled trials (RCTs). This study aimed to explore which formulas are the most effective and/or safest for Hp-associated gastritis. METHODS: We performed a search of electronic databases including PubMed, Web of Science, Cochrane Library, Embase, Chinese databases and South Korean database from inception to March 2022 to identify all relevant RCTs on the comparison between TCM combined with SQ and SQ for Hp-associated gastritis. Efficacy outcomes were the eradication rate of Hp and therapeutic response rate, and safety outcome was incidence of adverse reactions. Publication bias was assessed quantitatively using Egger's regression analysis and qualitatively using trim-and-fill method. Quality assessment was performed using Cochrane Risk of Bias, version 2 (ROB 2) tool. The Bayesian methods were applied to compare each treatment. RESULTS: A total of 55 trials with 6,187 patients were involved. The experimental group included 9 TCMs combined with SQ. The control group was SQ. The pair-wise meta-analysis demonstrated that compared with control group, 8 TCMs combined with SQ could statistically improve the eradication rate of Hp in patients with gastritis, 9 TCMs combined with SQ could significantly improve the therapeutic response rate. Additionally, Banxia Xiexin decoction combined with SQ (BXS) could statistically decrease the incidence of adverse reactions. The network meta-analysis results showed that BXS, Xiangsha Liujunzi combined with SQ (XSS), and Huangqi Jianzhong decoction combined with SQ (HQS) was the best measures to effectively eradicate Hp, enhance therapeutic effect, and decrease adverse reactions, respectively. The results of trim-and-fill method indicated that the results were stable and less affected by publication bias. CONCLUSIONS: Compared with SQ, TCM combined with SQ generally has a better clinical effect and higher safety in patients with Hp-associated gastritis. BXS, XSS, and HQS are recommended based on the patient's condition and needs in clinical practice. Further high-quality double-blinded RCTs are warranted to validate the conclusions.