Role of Acid Suppression in Acid-related Diseases: Proton Pump Inhibitor and Potassium-competitive Acid Blocker

Abstract

Proton pump inhibitors are commonly utilized for the treatment of gastric acid-related diseases, such as gastroesophageal reflux disease, peptic ulcer disease, and Helicobacter pylori infection, and for the prevention of low-dose aspirin or nonsteroidal anti-inflammatory drug-induced peptic ulcers. Vonoprazan is a first-in-class potassium-competitive acid blocker, which has distinct advantages compared to other conventional proton pump inhibitors in terms of the efficacy for acid suppression. Due to its strong gastric acid suppression capabilities, vonoprazan serves as an effective drug for the treatment of gastroesophageal reflux disease and H. pylori infection.

Keywords: Gastroesophageal reflux; Helicobacter pylori; Peptic ulcer; Potassium; Proton pump inhibitors.

Figure 1

Strategy of gastroesophageal reflux disease (GERD) treatment. (A) Conventional strategy of GERD treatment (an abridged edition of the Evidence-based Clinical Practice Guidelines for GERD 2015 published by the Japanese Society of Gastroenterology). Initial treatment is administration of proton pump inhibitor (PPI) standard dose for 8 weeks. Then, maintenance treatment is administration of PPI half dose daily. If incomplete healing occurs, maintenance with continuous PPI standard dose is permissible. On-demand PPI treatment is alternative management strategy. (B) The authors propose a new strategy of GERD treatment considering the effectiveness of potassium-competitive acid blocker (P-CAB). Initial treatment is 4-week treatment with P-CAB standard dose for severe erosive esophagitis. Four-week treatment with P-CAB or 8-week treatment with PPI are recommended as an initial therapy for mild erosive esophagitis or non-erosive reflux disease (NERD). Then, maintenance treatment is administration of P-CAB half dose daily. If incomplete healing, maintenance with continuous P-CAB standard dose is permissible. Continuous PPI standard or half dose daily is one of the options. On-demand P-CAB treatment is a workable alternative management strategy. The severity of reflux esophagitis is classified according to the Los Angeles classification. EE, erosive esophagitis.

Figure 2

Strategy of proton pump inhibitor (PPI)-resistant gastroesophageal reflux disease (GERD) treatment. (A) Conventional strategy of PPI-resistant GERD treatment (an abridged edition of the Evidence-based Clinical Practice Guidelines for GERD 2015 published by the Japanese Society of Gastroenterology). First choice is double dose PPI therapy. Switching to the other PPI is an option. Addition of prokinetics to PPI is effective in some cases. (B) The authors propose a new strategy of PPI-resistant GERD treatment. First choice is administration of potassium-competitive acid blocker (P-CAB) standard dose. Addition of prokinetics to P-CAB may have an additional effect.

Figure 3

Strategy of proton pump inhibitor (PPI)-resistant Helicobacter pylori (H. pylori) eradication treatment. (A) Conventional strategy of H. pylori eradication treatment (an abridged edition of Management of Helicobacter pylori infection—the Maastricht V/Florence Consensus Report published by the European Helicobacter and Microbiota Study Group). In areas of low clarithromycin (CAM) resistance (< 15%), amoxicillin (AMX), CAM, and PPI triple therapy is the recommended first-line treatment. In areas of high CAM resistance (> 15%) and low metronidazole (MTZ) resistance (< 15%), AMX, MTZ, and PPI triple therapy is recommended. In areas of dual resistance, bismuth quadruple therapy is recommended. Quinolone containing therapy and bismuth quadruple therapy are recommended as rescue therapy. (B) The authors propose a new strategy of H. pylori eradication treatment. AMX, CAM, and potassium-competitive acid blocker (P-CAB) triple therapy is sufficient treatment even for CAM resistant strains. AMX, MTZ, P-CAB, or PPI triple therapy, quinolone containing therapy and bismuth quadruple therapy may be recommended as rescue therapy.