Effect of H. pylori Eradication on Platelet Response in Immune Thrombocytopenia: A Systematic Review and Meta-analysis of RCTs

Background Helicobacter pylori (H. pylori) has been implicated in immune thrombocytopenia (ITP), but the magnitude and reliability of benefit from eradication therapy in randomized trials remain uncertain. Methods We performed a PRISMA-guided, PROSPERO-registered (CRD420251149478) systematic review and meta-analysis restricted to randomized controlled trials (RCTs) comparing H. pylori eradication versus control in ITP. Random-effects models (R) generated risk ratios (RRs) for categorical outcomes—complete response (CR; 8 trials), partial response (PR; 5), overall response (CR + PR; 8), no/minimal response (NR; 8), and 1-year relapse (3)—and mean difference (MD) for platelet count change at ~ 6 months (5). Heterogeneity (I²/τ²), leave-one-out sensitivity, and funnel plots with Egger/Begg tests assessed robustness and small-study effects. Results Eight RCTs (n = 297) across Asia and Latin America met inclusion. Eradication increased CR without statistical significance (RR 1.45, 95% CI 0.87–2.41; I²=40.9%) and did not change PR (RR 0.88, 0.57–1.36; I²=0%) or overall response (RR 1.04, 0.90–1.20; I²=35.9%). NR was significantly lower with eradication (RR 0.65, 0.49–0.85; I²=14.8%). Relapse at 1 year trended lower but was not significant (RR 0.49, 0.24–1.01; I²=0%). Platelet counts rose more after eradication at ~ 6 months (MD + 61.9×10⁹/L, 36.1–87.7; I²=74.9%). Leave-one-out analyses did not alter conclusions. Funnel plots and tests suggested asymmetry for CR and overall response; PR and NR showed no evidence of small-study effects; relapse and platelet change were underpowered for definitive bias testing. Adverse events were mild and infrequently reported; no serious events were attributed to eradication. Conclusions In RCTs, H. pylori eradication for ITP significantly reduces non-response and yields a clinically meaningful platelet rise, while effects on categorical CR/PR and overall response are neutral and relapse reduction is borderline. Given its safety, low cost, and biologic plausibility, testing and offering eradication should be considered early—especially in high-prevalence regions—pending larger multicenter trials to define predictors and durability of benefit.