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