Are Potassium-Competitive Acid Blockers Superior to PPIs for GERD Treatment?

Prateek Sharma, MD, FASGE reviewing Xiao Y, et al. Gut 2019 Aug 13.

Proton pump inhibitors (PPIs) are widely used for the treatment of GERD, including healing erosive esophagitis. Since several PPIs have a slow, cumulative onset of action that can take 3 to 5 days to produce maximum acid-inhibitory effects, a class of acid-inhibitory agents called potassium-competitive acid blockers (PCABs) has been developed that could potentially demonstrate maximum acid-inhibitory effects from the first day. 

This multicenter, randomized, double-blind study was conducted in Asia to compare the efficacy and safety of vonoprazan (a PCAB) with lansoprazole (a PPI) in patients with erosive esophagitis. A total of 481 patients (mean age 53.9 years, 74% males) were randomized to either 20 mg of vonoprazan (n=232) or 30 mg of lansoprazole (n=224) once daily for up to 8 weeks, with serial endoscopies performed at 2, 4, and 8 weeks. At the end of 8 weeks, the healing rates in the vonoprazan and lansoprazole groups were 92.4% and 91.3%, respectively (difference, 1.1%; 95% CI, -3.8 to 6.1). The 2- and 4-week healing rates were also similar between the 2 groups. In patients with severe grades of erosive esophagitis (Los Angeles [LA] classification grades C and D), healing rates were numerically better in the vonoprazan compared to the lansoprazole group (2 weeks: 62% vs 52%; 4 weeks: 73% vs 67%; 8 weeks: 84% vs 81%). Treatment-emergent adverse events were noted in 38% of vonoprazan recipients and 37% of lansoprazole recipients, but the majority of the events were not related to the study drugs. Serious adverse events occurred in 3 patients in each treatment group, and none of these events were related to the study drugs.


Comment:
GERD-related erosive esophagitis can be successfully healed by both PPIs and PCABs. The proposed faster onset action of PCABs does not lead to quicker healing of esophagitis; however, there may be a PCAB role in higher grades of erosive esophagitis (LA grades C and D).

Prateek Sharma, MD, FASGE
Bio and Disclosures

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Citation(s):
Xiao Y, Zhang S, Dai N, et al. Phase III, randomised, double-blind, multicentre study to evaluate the efficacy and safety of vonoprazan compared with lansoprazole in Asian patients with erosive oesophagitis. Gut 2019 Aug 13. (Epub ahead of print) (https://doi.org/10.1136/gutjnl-2019-318365)