Heartburn is common enough that most people treat it as a mild nuisance that can be calmed with an antacid and forgotten about. When heartburn becomes recurrent, however, that mild nuisance may be a symptom of a much more disruptive condition called gastroesophageal reflux disease (GERD). Treatments that suppress stomach acid may provide relief in these cases, but for some people the symptoms return as soon as treatment stops. A newer prescription drug called vonoprazan offers another treatment option for patients with GERD.

What Is GERD?

Heartburn and gastroesophageal reflux disease (GERD) are closely related but aren’t interchangeable. Heartburn is the familiar burning sensation associated with acid reflux, which is when stomach contents flow backward into the esophagus. An occasional episode of reflux, particularly after a large or heavy meal, doesn’t necessarily mean that someone has GERD or will eventually develop it. Instead, GERD refers to a more persistent pattern in which reflux occurs often enough to cause recurring symptoms or other complications.

In general, GERD develops when the normal barrier between the stomach and esophagus fails to prevent stomach contents from moving upward. Because the lining of the esophagus is not optimized for repeated exposure to stomach acid, frequent reflux can irritate the tissue and create the sensation of heartburn. Some patients may also experience regurgitation, which is when food or stomach acid rises up to the back of the throat, and others have less typical symptoms like a chronic cough or hoarseness.

An important distinction in evaluating GERD and determining the treatment approach is whether an endoscopy reveals visible damage to the esophagus. When reflux symptoms occur without visible erosions, the condition is considered non-erosive GERD. When repeated acid exposure causes inflammation or breaks in the esophageal lining, it is considered erosive esophagitis. Gastroenterologists weigh this distinction when determining the goals of treatment and how aggressively stomach acid needs to be suppressed.1

PPIs and Stomach Acid

Because GERD involves repeated exposure of the esophagus to stomach acid, the traditional approach to treatment has been to reduce how much acid the stomach produces. Since the late 1980s, proton pump inhibitors (PPIs) like omeprazole, pantoprazole, and esomeprazole have been the main way to bring relief for GERD patients. Rather than neutralizing acid that has already been produced (as with antacids), PPIs work by acting on the cells that generate the acid in the first place.

Stomach acid is produced by specialized cells found in the stomach lining called parietal cells. These cells contain an enzyme (H+/K+-ATPase) that helps create the acidic environment necessary for digestion by exchanging hydrogen ions (H+) for potassium ions (K+). A hydrogen ion is essentially a proton, which is why the enzyme is commonly known as the gastric proton pump and medications that block it are called proton pump inhibitors. With fewer pumps pumping, the stomach produces less acid and any contents that reflux into the esophagus are less acidic and therefore less irritating.

While PPIs are effective for many patients, one of their limitations is that the medication primarily works on pumps that are actively producing acid at the time. This means that most PPIs need to be taken before a meal so that the act of eating will stimulate more of the pumps into action. In addition to the challenge of timing the medication properly (30-60 minutes before a meal), a single dose cannot shut down all of the stomach’s proton pumps at once. As a result, the degree of acid suppression can vary and repeated daily doses are needed to reach the medication’s full effect.2

How Does Vonoprazan Work Differently?

PPIs remain a highly effective treatment for GERD, but some cases may require stronger or less timing-dependent acid suppression. Vonoprazan belongs to a newer class of medications called potassium-competitive acid blockers (PCABs) that block gastric proton pumps through a different mechanism. Rather than requiring acid activation before binding to the pump, vonoprazan competes with potassium at the pump itself, blocking the hydrogen-potassium exchange step of acid production.

Because of how it inhibits this hydrogen-potassium exchange, the acid-suppressing effect of vonoprazan doesn’t rely on meal timing. A dose begins raising stomach pH levels (and thus reducing acidity) relatively quickly and continues suppressing acid production for 24 hours or longer. The fact that it isn’t reliant on affecting proton pumps during a particular window allows it to provide stronger and more sustained acid suppression than traditional PPIs in some patients.

In the United States, vonoprazan is sold under the brand name Voquezna and is approved for several GERD-related uses in adults. These include healing erosive esophagitis, maintaining healing after erosive esophagitis has resolved, and relieving heartburn associated with non-erosive GERD. Its different mechanism does not mean it is automatically a better choice than a PPI for every patient, but it gives gastroenterologists another option when stronger or more consistent acid suppression may be useful.

When Might a Doctor Prescribe Vonoprazan?

One scenario where a gastroenterologist might consider vonoprazan is if an endoscopy reveals extensive damage to the esophageal lining. Patients with severe erosive esophagitis, for instance, can benefit from stronger and more sustained acid suppression because reducing acid exposure gives the damaged tissue a better opportunity to heal. A major clinical trial comparing vonoprazan with the PPI lansoprazole found that the difference in healing rates was greater among patients with this more extensive form of erosive disease.3

Another reason vonoprazan may be recommended is when the patient has consistent GERD symptoms despite appropriate treatment with a PPI. Before changing medications, a doctor will generally want to make sure the PPI is being taken correctly and that ongoing acid reflux is actually responsible for the symptoms. Heartburn-like discomfort can have other causes, and simply using a stronger acid suppressant will not help if acid is not the underlying problem. When GERD is confirmed and acid suppression remains inadequate, however, vonoprazan may provide another option.

As promising as vonoprazan is for treating severe forms of GERD, it won’t be the right choice for every patient. People with significant kidney or liver impairment, for example, may need a lower dose when the medication is being used to heal erosive esophagitis. Vonoprazan can also interact with certain prescription drugs, including some HIV medications and clopidogrel. Common side effects reported during treatment for erosive esophagitis include diarrhea, abdominal pain, nausea, bloating, and gastritis.

Contact Cary Gastro to Learn More

If you have persistent heartburn or have been diagnosed with GERD and are still struggling with symptoms, vonoprazan may be an option worth discussing with a gastroenterologist. The physicians at Cary Gastro can evaluate your GERD symptoms, determine whether additional testing or a change in treatment may be appropriate, and answer questions about GERD medications. Contact Cary Gastro today to request an appointment and learn more about the treatment options available.




1https://pmc.ncbi.nlm.nih.gov/articles/PMC8754510/
2https://pmc.ncbi.nlm.nih.gov/articles/PMC11189022/
3https://pubmed.ncbi.nlm.nih.gov/36228734/