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

Abstract Purpose Potassium-competitive acid blockers (PCABs) are a unique class of acid-suppressing agents with favorable pharmacokinetic properties offering quick onset and durable acid suppression in nearly all patients. The use of vonoprazan, a PCAB recently approved in the United States (US) for erosive esophagitis (EE), is absent from formal society guidelines despite recent expert clinical updates. Expert consensus recommends proton pump inhibitors (PPIs) as first-line therapy, reserving vonoprazan for PPI-refractory or severe esophagitis cases. This study examines real-world vonoprazan prescribing patterns. Methods We conducted a retrospective cohort study using TriNetX, a de-identified health research network with data from over 150 million patients (accessed November 3, 2025). Adults with a new diagnosis of EE in 2024 were included. Two cohorts were defined: vonoprazan users and PPI users. Relevant clinical characteristics and vonoprazan doses were extracted; differences between groups were described using standardized mean differences (SMDs). Results Among patients newly diagnosed with EE in 2024, 119,578 received PPIs and 1,524 received vonoprazan. In the US, the South had the highest proportion of vonoprazan users (37.84%). Compared with the PPI cohort, the vonoprazan group had higher rates of gastrointestinal comorbidities (including hiatal hernia, Barrett’s esophagus, esophageal strictures and gastritis), reflux-related symptoms and diagnostic evaluations for refractory disease. Among vonoprazan users, 50.49% received it as their first recorded therapy after the EE diagnosis and 27.99% as second recorded therapy, with pantoprazole being the most common PPI preceding vonoprazan prescription. Vonoprazan 20 mg dose was more frequently used (59.6%) than the 10 mg dose (22.6%); dose switching was infrequent. Conclusion In this real-world cohort, patients receiving vonoprazan demonstrated greater disease complexity. An important concern is the inability to assess underlying esophagitis severity due to database limitations. The initial dose was predominantly 20 mg daily with infrequent dose reduction within our time frame. Further evaluation of treatment duration and clinical outcomes is needed for a complete assessment of the real-world use of vonoprazan.