Vonoprazan

Aka: Vonoprazan, Voquezna, Takecab

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II. Indications

  1. Erosive Esophagitis
  2. Nonerosive Gastroesophageal Reflux Disease
  3. Helicobacter Pylori

III. Mechanism

  1. Potassium Competitive Acid Blocker (PCAB)
    1. Similar mechanism as Proton Pump Inhibitors (PPIs)
  2. In addition to blocking active proton pumps (as with PPIs), PCABs also block resting proton pumps
    1. Allows for PCAB onset of activity within hours (as compared with days for PPIs)
    2. PCABs may be taken with or without food (contrast with PPIs taken 60 minutes before eating)

IV. Dosing: By Indications

  1. See indications for low dose (10 mg/day) in renal and liver disease as below
  2. Healing of Erosive Esophagitis and GERD Relief
    1. Vonoprazin 20 mg orally daily for 8 weeks
    2. Decrease dose to 10 mg orally daily if GFR <30 ml/min
  3. Maintenance of Healed Erosive Esophagitis and GERD Relief
    1. Vonoprazin 10 mg orally daily for up to 6 months
  4. Nonerosive GERD
    1. Vonoprazin 10 mg orally daily for 4 weeks
  5. Helicobacter Pylori
    1. Vonoprazan 20 mg orally twice daily AND Antibiotics
    2. Packaged with Antibiotics (Amoxicillin and Clarithromycin)
      1. Voquezna Triple Pak (Vonoprazan, Amoxicillin, Clarithromycin)
      2. Voquezna Dual Pak (Vonoprazan, Amoxicillin)
    3. However, no evidence for greater efficacy for PCABs than the much lower cost Proton Pump Inhibitors
      1. Lower efficacy than quadruple therapy
      2. At $800 in 2022, the cost is four fold higher than standard quadruple therapy

V. Dosing: By Strength

  1. High Dose: 20 mg orally twice daily
    1. Helicobacter Pylori Management
  2. Moderate Dose: 20 mg orally daily
    1. Gastric Ulcer or Duodenal Ulcer
    2. Gastroesophageal Reflux (GERD)
  3. Low Dose: 10 mg orally daily
    1. Reflux Esophagitis prevention
    2. Aspirin or NSAID induced Peptic Ulcer prevention
    3. Renal Dosing (GFR <30 ml/min)
    4. Child-Pugh Class B or C
    5. NOT recommended for Helicobacter Pylori

VI. Efficacy

  1. Vonoprazin is $200/month (up to $650/month) in 2026 (far more expensive than PPIs)
  2. Vonoprazin has shown no benefit over Proton Pump Inhibitors (PPIs)
    1. Vonoprazin 20 mg is similar to Lansoprazole (Prevacid) 30 mg for erosive Esophagitis healing at 4 weeks
    2. Vonoprazin is not better than PPIs for the prevention and treatment of Peptic Ulcer Disease (gastric or duodenal)
      1. Simadibrata (2024) Dig Dis Sci 69(10):3863-74 +PMID: 39294424 [PubMed]

VII. Adverse Effects

  1. Diarrhea
  2. Nausea
  3. Longterm adverse effects are similar to Proton Pump Inhibitors
    1. Increased Fracture risk
    2. Clostridioides difficile
    3. Vitamin B12 Deficiency
    4. Hypomagnesemia (and Hypokalemia, Hypocalcemia)
  4. Atypical and rare serious effects
    1. Fundic gland polyps
    2. Acute Tubulointerstitial Nephritis
    3. Stevens Johnson Syndrome
    4. Toxic Epidermal Necrolysis

VIII. Safety

  1. Unknown safety in pregnancy
  2. Unknown safety in Lactation

IX. Drug Interactions

  1. CYP3A4 Inducers
    1. Decrease Vonoprazin efficacy

X. Resources

  1. Vonoprazin (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=0cc52ac5-77ec-4d66-a770-762a1a960914

XI. References

  1. (2024) Presc Lett 31(1): 5

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