INTRODUCTION: Los Angeles grade C/D esophagitis is a severe manifestation of gastroesophageal reflux disease that require active treatment and close follow-up. Potassium competitive acid blockers (P-CAB) are promising alternatives to proton pump inhibitors (PPI). We aimed to compare the efficacy and safety of P-CAB and PPI in healing grade C/D esophagitis to aid clinical decision-making.
METHODS: A systematic literature search was performed using PubMed, MEDLINE, and Cochrane Central Register of Controlled Trials. Randomized controlled trials were eligible for inclusion if efficacy of P-CAB and PPI in healing grade C/D esophagitis was reported. Pooled risk ratios and risk difference with 95% credible intervals were used to summarize estimated effect of each comparison. The benefit of treatments was ranked using the surface under the cumulative probability ranking score.
RESULTS: Of 5,876 articles identified in the database, 24 studies were eligible. Studies included incorporated 3 P-CAB (vonoprazan, tegoprazan, and keverprazan) and 6 PPI (lansoprazole, esomeprazole, omeprazole, rabeprazole extended-release (ER), pantoprazole, and dexlansoprazole). Based on the failure to achieve mucosal healing, 20 mg of vonoprazan q.d. ranked the first among PPI in initial and maintained healing of grade C/D esophagitis (surface under the cumulative probability ranking score = 0.89 and 0.87, respectively). Vonoprazan had similar risk of incurring adverse events, severe adverse events, and withdrawal to drug when compared with PPI. For those who attempted lower maintenance treatment dose, 10 mg of vonoprazan q.d. was a reasonable choice, considering its moderate efficacy and safety.
DISCUSSION: Vonoprazan has considerable efficacy in initial and maintained healing of grade C/D esophagitis compared with PPI, with moderate short-term and long-term safety.
| Specialty | Score |
|---|---|
| Gastroenterology | |
| Internal Medicine | |
| Family Medicine (FM)/General Practice (GP) | |
| General Internal Medicine-Primary Care(US) |
Interesting new class of therapy, but not available in most jurisdictions, including Canada.
NOT based on head-to-head comparisons, so the conclusions are not definitive.
These are new medications, so not currently able to use these data.
This review article compared efficacy in Grade C/D esophagitis of potassium competitive acid blockers (P-CAB) and PPIs. Vonoprazan, a P-CAB, was more effective at healing and maintenance of healing than other medications studied (6 PPIs and 2 other P-CABs), with similar adverse effect rates. Efficacy was reflected in treatment and maintenance of healing by 11-21% improvements over PPIs as a class. This marked improvement is tempered, however, by cost and availability - some plans allow for 30 pills of 40mg pantoprazole for 6 dollars, while vonoprazan is around 100x that. An interesting paper and perhaps a sign of things to come, but at this time cost and availability are likely to attenuate P-CABs clinical superiority.
This article is highly relevant as P-CABs may reflect a more promising option to high-grade erosive esophagitis, particularly when this is refractory to PPIs. Current adjunct therapies (i.e., sucralfate) are often inconvenient for patients and have limited efficacy. These medications will likely be commercially available in the near future. This paper positions P-CABs well compared with PPIs and allows readers to understand the indications and common adverse effects. It would be ideal to have data comparing P-CABs to maximal PPI dosing. The authors address well the limitations in the available data.
, McMaster University