Comparison of TAK-438 (Vonoprazan) to Lansoprazole in the Treatment of Duodenal Ulcer Participants With or Without Helicobacter Pylori Infection

The drug being tested in this study is called TAK-438. TAK-438 is being tested to treat people who have duodenal ulcers and also may or may not have Helicobacter pylori (HP) infection. This study will look at duodenal ulcer healing and also the elimination of HP in people who take TAK-438 versus lansoprazole. The study will enroll approximately 530 patients.

Participants were randomly assigned (by chance, like flipping a coin) to one of the two treatment groups-which remained undisclosed to the participant and study doctor during the study (unless there is an urgent medical need):

* TAK-438 20 mg
* Lansoprazole 30 mg

HP+ participants will be asked to take a TAK- 438 tablet and a lansoprazole capsule twice daily in conjunction with bismuth-containing quadruple therapy for 2 weeks, followed up by a TAK-438 tablet and a lansoprazole capsule once daily for up to 4 weeks. HP negative (HP-) participants will be asked to take a TAK-438 tablet and a lansoprazole capsule once daily for up to 6 weeks.

This multi-center trial will be conducted China, Korea and Taiwan. The overall time to participate in this study is up to 10 weeks. Participants will make multiple visits plus final visit at 2 weeks or 4 weeks after last dose of study drug for a follow-up assessment.

• TAK-438 (Drug), also known as Vonoprazan: TAK-438 tablets
• Lansoprazole (Drug), also known as Prevacid: Lansoprazole capsules
• TAK-438 Placebo (Drug): TAK-438 placebo-matching tablets.
• Lansoprazole Placebo (Drug): Lansoprazole placebo-matching capsules
• Bismuth-Containing Quadruple Therapy (Drug): 1 g Amoxicillin, 500 mg clarithromycin and 600 mg bismuth potassium citrate/bismuth tripotassium dicitrate, twice daily (BID).

Primary outcomes

• Percentage of Participants With Endoscopically Confirmed Healing of Duodenal Ulcers [Week 4 or Week 6]: Endoscopic healing was defined as the disappearance of all white coats associated with duodenal ulcers as confirmed endoscopically.

Secondary outcomes

• Percentage of Helicobacter Pylori Infected (HP+) Participants With Successful HP Eradication After 4 or 6 Weeks of Treatment [4 weeks post treatment (Up to 10 weeks)]: HP infection status was determined by \^13C Urea Breath Test (\^13C-UBT). The urea breath test is used to detect infection with HP, a bacteria associated with stomach ulcers, by testing individual breath samples in a central laboratory.
• Percentage of Participants With Endoscopically Confirmed Healing of Duodenal Ulcer at Week 4 [Week 4]: Endoscopic healing is defined as the disappearance of all white coats associated with duodenal ulcers as confirmed endoscopically.
• Percentage of Participants With Posttreatment Resolution of Gastrointestinal Symptoms Associated With Duodenal Ulcer at Weeks 2 Through 6 [Week 2 up to Week 6]: The percentage of participants with resolution of various gastrointestinal symptoms are reported as categories. Gastrointestinal symptoms included epigastric pain (postprandial, fasting, nocturnal), abdominal bloating, nausea/vomiting, heartburn and lack of appetite. The severity of subjective symptoms of erosive esophagitis were recorded as: none = 0, mild = 1, moderate = 2 or severe = 3.

Sex: All, ages: 18 Years to any

Inclusion Criteria:

1\. Has endoscopic evidence of active duodenal ulcer(s) (i.e., mucosal defects with white coating \[including cases associated with blood coagulation as long as there is no active bleeding\]) measuring 5 mm or larger in longest diameter within 14 days prior to randomization.

Exclusion Criteria:

1. Has received TAK-438 in a previous clinical study or as a therapeutic agent.
2. Has a history or clinical manifestations of significant central nervous system (CNS), cardiovascular, pulmonary, hepatic, renal, metabolic, gastrointestinal, urological, endocrine or hematological disease that, in the opinion of the investigator, would confound the study results or compromise participant safety.
3. Has been treated with Helicobacter pylori eradication therapy within 30 days prior to study treatment.
4. Has a diagnosis of duodenal malignancy or a duodenal ulcer whose morphology suggested malignancy as evident by endoscopy within 14 days prior to randomization.
5. Is suspected of having acute gastro-duodenal mucosal lesions (AGDML) as evident by endoscopy within 14 days prior to randomization.
6. Has a linear ulcer (including a linear ulcer scar) that has been confirmed as evident by endoscopy within 14 days prior to randomization.
7. Has active postoperative (eg, endoscopic mucosal resection / endoscopic submucosal dissection) ulcer(s) as confirmed by endoscopy within 14 days prior to randomization.
8. Has gastric ulcer that has been confirmed by endoscopy within 14 days prior to randomization.
9. Has ulcers for which medical therapy alone is not indicated (eg, perforation, pyloric stenosis, duodenal stenosis, major bleeding).
10. Has undergone therapeutic upper gastrointestinal (GI) endoscopic therapy (eg, endoscopic hemostasis or excision including biopsy) within 30 days prior to visit 1.
11. Has Zollinger-Ellison syndrome or gastric acid hypersecretion or those with a history of gastric acid hypersecretion.
12. Has undergone major surgical procedures within 30 days prior to Visit 1 or are scheduled to undergo surgical procedures that may affect gastric acid secretion (eg, abdominal surgery, vagotomy or craniotomy).
13. Has a history of malignancy or was treated for malignancy within 5 years before the start of the visit 1 (the participant may be included in the study if he/she has cured cutaneous basal cell carcinoma or cervical carcinoma in situ).
14. Has a known acquired immunodeficiency syndrome (AIDS) or hepatitis infection, including hepatitis virus carriers (hepatitis B surface-antigen \[HBsAg\] - or hepatitis C virus (HCV)-antibody-positive) (the participant may be included in the study if he/she is HCV-viral load-RNA-negative).
15. Laboratory tests performed prior to randomization revealed any of the following abnormalities in the participant:

    1. Creatinine levels: >2 mg/dL (>177 μmol/L).
    2. Alanine aminotransferase (ALT) or aspartate aminotransferase (AST), or total bilirubin levels: > upper limit of normal (ULN).
16. Has hypersensitivity to TAK-438, proton pump inhibitors (PPIs), bismuth, clarithromycin, or amoxicillin. Skin testing may be performed according to local standard practice (for HP+ participants only).

Participant flow

Outcome results

• Percentage of Participants With Endoscopically Confirmed Healing of Duodenal Ulcers (Primary), Number, percentage of participants: TAK-438 20 mg 96.9 (93.889 to 98.631); Lansoprazole 30 mg 96.5 (93.406 to 98.374)
• Percentage of Helicobacter Pylori Infected (HP+) Participants With Successful HP Eradication After 4 or 6 Weeks of Treatment (Secondary), Number, percentage of participants: TAK-438 20 mg 91.5 (86.853 to 94.866); Lansoprazole 30 mg 86.8 (81.330 to 91.093)
• Percentage of Participants With Endoscopically Confirmed Healing of Duodenal Ulcer at Week 4 (Secondary), Number, percentage of participants: TAK-438 20 mg 89.2 (84.617 to 92.731); Lansoprazole 30 mg 88.4 (83.830 to 92.124)
• Percentage of Participants With Posttreatment Resolution of Gastrointestinal Symptoms Associated With Duodenal Ulcer at Weeks 2 Through 6 (Secondary), Number, percentage of participants: TAK-438 20 mg 87.7 (76.321 to 94.917); Lansoprazole 30 mg 91.8 (80.399 to 97.731)

Adverse events

Time frame: Up to Week 10 (Up to 6 weeks of treatment)

Serious adverse events by term

Other adverse events by term

• Results publication: Hou X, Wang J, Du Q, Tian D, Hu N, Liu D, Zhou F, Xie L, Gu L, Kudou K, Zhang S. Efficacy and Safety of Vonoprazan-Based Quadruple Therapy for the Eradication of Helicobacter pylori in Patients with Peptic Ulcers: A Pooled Analysis of Two Randomized, Double-Blind, Double-Dummy, Phase 3 Trials. Biol Pharm Bull. 2024;47(8):1405-1414. doi: 10.1248/bpb.b24-00011. PMID 39085080

• Study Protocol (PDF, 2018-08-30)
• Statistical Analysis Plan (PDF, 2019-07-23)

• Medical Director Clinical Science, Study director, Takeda