S934 Potassium-Competitive Acid Blockers Versus Proton Pump Inhibitors in Patients With Grade C and D Erosive Esophagitis: A Meta-Analysis

Introduction: Severe erosive esophagitis, defined as Los Angeles Classification Grades C and D, remains a therapeutic challenge due to suboptimal healing rates despite treatment with proton pump inhibitors (PPIs). Potassium-competitive acid blockers (PCABs), which provide more potent and sustained acid suppression, may offer improved healing outcomes. We conducted a meta-analysis to compare the efficacy and safety of PCABs versus PPIs in patients with Grade C or D erosive esophagitis. Methods: A comprehensive electronic search was conducted through February 2025 to identify randomized controlled trials (RCTs) comparing PCABs and PPIs in this patient population. The primary outcome was endoscopic healing at 4 and 8 weeks. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using a random-effects model (RevMan 5.4.1) to account for heterogeneity. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. A subgroup analysis was performed comparing studies with equivalent doses of the same PCAB and PPI. Results: Six RCTs involving 2,836 patients (1,433 receiving PCABs and 1,403 receiving PPIs) were included from 1,208 citations. The studies evaluated vonoprazan, zastaprazan, and fexuprazan (PCABs), and lansoprazole and esomeprazole (PPIs). In the subgroup analysis of 4 studies comparing vonoprazan 20 mg with lansoprazole 30 mg, vonoprazan demonstrated significantly higher healing rates at both 4 and 8 weeks: RR 1.12 (95% CI 1.03-1.21; P = 0.005) at 4 weeks, and RR 1.12 (95% CI 1.01-1.24; P = 0.005) at 8 weeks. After including the 2 additional studies comparing other PCABs and PPIs, the pooled RR at 4 weeks was 1.09 (95% CI 0.97-1.22; P = 0.76), and at 8 weeks was 1.08 (95% CI 0.97-1.20; P = 0.23). Conclusion: In our meta-analysis of equivalent doses and agents, PCABs demonstrated superior healing rates compared to PPIs in patients with Grade C and D erosive esophagitis. These findings support considering PCABs as a preferred first-line therapy in severe cases. Faster mucosal healing may translate into reduced healthcare utilization and improved long-term outcomes.