Vonoprazan Prescribed Mostly to Complex Erosive Esophagitis Cases in Real-World Cohort

A retrospective cohort study drawing on a large de-identified US health research network has mapped how the newly approved acid suppressant vonoprazan is actually being prescribed for erosive esophagitis, and the picture is one of selective, complexity-driven use. Among adults newly diagnosed with erosive esophagitis in 2024, 119,578 patients received a proton pump inhibitor while only 1,524 received vonoprazan, a potassium-competitive acid blocker approved in the United States for the condition. The study, published in BMC Gastroenterology, used TriNetX data from more than 150 million patients, accessed on November 3, 2025.

Vonoprazan belongs to a distinct class of acid-suppressing agents with pharmacokinetic properties that allow a quick onset and durable acid suppression in nearly all patients. Despite this, formal society guidelines have not yet incorporated the drug, although recent expert clinical updates address it. Current expert consensus recommends proton pump inhibitors as first-line therapy, reserving vonoprazan for patients whose disease is PPI-refractory or whose esophagitis is severe.

The data suggest it largely does. Compared with the PPI cohort, patients placed on vonoprazan had higher rates of gastrointestinal comorbidities, including hiatal hernia, Barrett’s esophagus, esophageal strictures and gastritis, along with more reflux-related symptoms and more diagnostic evaluations for refractory disease. Regionally, the US South accounted for the highest proportion of vonoprazan users at 37.84%.

The sequencing of therapy also points toward vonoprazan as a second-line option for many patients. Among vonoprazan users, 50.49% received it as their first recorded therapy after the erosive esophagitis diagnosis, while 27.99% received it as second recorded therapy. Pantoprazole was the most common proton pump inhibitor prescribed before a switch to vonoprazan, indicating that many patients had already been exposed to standard acid suppression before moving to the newer agent.

Dosing patterns were similarly concentrated. The 20 mg dose was used more frequently than the 10 mg dose, at 59.6% versus 22.6% of initial prescriptions, and dose switching was infrequent. The authors conclude that in this real-world cohort, patients receiving vonoprazan demonstrated greater disease complexity, and note that the initial dose was predominantly 20 mg daily with infrequent dose reduction within the study’s time frame.

The study’s authors flag an important limitation: the database did not allow assessment of underlying esophagitis severity, a key factor in guideline-based selection of vonoprazan. They also note that further evaluation of treatment duration and clinical outcomes is needed before a complete assessment of real-world vonoprazan use is possible. As an early-access, peer-reviewed accepted article, the published version remains subject to further edits before the final Version of Record.

Subject of Research: Real-world prescribing patterns of vonoprazan, a potassium-competitive acid blocker, in US adults with erosive esophagitis

Article Title: Real-world prescription patterns of potassium-competitive acid blockers (PCABs) in erosive esophagitis: a retrospective cohort study

Article References: Chalhoub, M., Chan, M. Q., Kurin, M., Skeans, J., & Shah, R. (2026). Real-world prescription patterns of potassium-competitive acid blockers (PCABs) in erosive esophagitis: a retrospective cohort study. BMC Gastroenterology. https://doi.org/10.1186/s12876-026-05375-3

Image Credits: AI Generated

DOI: 10.1186/s12876-026-05375-3

Keywords: vonoprazan, potassium-competitive acid blockers, erosive esophagitis, proton pump inhibitors, prescription patterns, retrospective cohort study, TriNetX, gastroenterology, acid suppression, refractory reflux disease, Real-world, prescription