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Update on the Use of Vonoprazan: A Competitive Acid Blocker

2018; Elsevier BV; Volume: 154; Issue: 3 Linguagem: Inglês

10.1053/j.gastro.2018.01.018

1528-0012

David Y. Graham, Maria Pina Dore,

Intestinal and Peritoneal Adhesions

Vonoprazan can be considered as a potent and long-acting PPI with some potential advantages over traditional PPIs. Both PPIs and vonoprazan therapy can be tailored to achieve more or less acid inhibition allowing the degree of acid suppression to be tailored to the need. Current clarithromycin- and vonoprazan-containing H pylori eradication therapies likely result in misuse of clarithromycin or metronidazole.30Shiotani A. Lu H. Dore M.P. Graham D.Y. Treating Helicobacter pylori effectively while minimizing misuse of antibiotics.Cleve Clin J Med. 2017; 84: 310-318Crossref PubMed Scopus (49) Google Scholar Vonoprazan offers the promise of being able to reliably achieve an intragastric pH of >5 and possibly >6, which may make it useful as an adjuvant to preventing recurrent bleeding after endoscopic hemostasis or for H pylori eradication therapy and to reliably achieve high cure rates with amoxicillin plus an antisecretory agent therapy. Vonoprazan may also assist in the management of fat malabsorption in patients with pancreatic insufficiency. Currently available enteric-coated pancreatic enzyme microbeads tend to dissociate from the meal and dissolve slowly and unpredictably during passage through the small intestine, precluding coordinated emptying of enzymes and nutrients. Unprotected enzymes mix well and empty with nutrients, but are inactivated at a pH of ≤4. The ability to reliable maintain an intragastric pH of >4 for very long periods may allow routine use of non–enteric-coated enzymes.31Trang T. Chan J. Graham D.Y. Pancreatic enzyme replacement therapy for pancreatic exocrine insufficiency in the 21(st) century.World J Gastroenterol. 2014; 20: 11467-11485Crossref PubMed Scopus (67) Google Scholar The long duration of action, good bioavailability, stability in acid, and inhibition of both active and inactive proton pumps suggest that vonoprazan may also be useful for difficult to manage patient such as those with Roux-en-Y gastric bypass or other bariatric surgeries in which lack of antral release of gastrin, rapid gastric emptying, and the small absorptive area for dissolution and absorption of enteric-coated PPIs make traditional antisecretory therapy difficult.32Tansel A. Graham D.Y. New insight into an effective treatment of marginal ulceration after Roux-en-Y gastric bypass.Clin Gastroenterol Hepatol. 2017; 15: 501-503Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Currently, vonoprazan plays an important and unique role when more acid suppression is needed than can be obtained with 60–70 mg of OE bid. However, situations are rare and, except for Zollinger–Ellison syndrome, would generally be of short duration. Whether vonoprazan is appropriate and safe for long-term, even life-long, use remains to be determined.