Another way to manage GERD

If you're living with gastroesophageal reflux disease, or GERD (in which stomach acid periodically flows back up into the esophagus, causing heartburn and other symptoms), you know that managing this long-term condition takes a comprehensive approach: lifestyle changes, like losing weight and avoiding certain foods may be all you need to do. Often, bothersome symptoms recur despite lifestyle changes; fortunately, there are a number of effective medications available.

But if you don't get enough relief from traditional treatments - especially if you have severe or frequent GERD symptoms, or if years of reflux have damaged your esophagus - a new class of drugs called potassium-competitive acid blockers, or P-CABs, "offers a helpful alternative," says Dr. Lawrence S. Friedman, chair of the Department of Medicine at Newton-Wellesley Hospital and a professor of medicine at Harvard Medical School.

How P-CABs are used

The only P-CAB available so far in the United States is vonoprazan (Voquezna), which is approved and available by prescription only for treating the following conditions in adults:

• erosive esophagitis (in which chronic acid reflux damages the lining of the esophagus)
• heartburn associated with non-erosive GERD (in which symptoms like heartburn and regurgitation occur, but without visible damage to the esophagus)
• refractory (treatment-resistant) peptic ulcer disease
• infections with H. pylori - a bacterium that infects the stomach lining and is a common cause of ulcers. With H. pylori infections, GERD medications (such as vonoprazan) is taken in combination with antibiotics.

Other P-CABs may soon be available, adds Dr. Friedman. These include tegoprazan, keverprazan, and fexuprazan, now available in some Asian countries.

Traditional GERD treatments

Clinical trials suggest that P-CABs may help people who have not responded well to standard GERD therapy. To understand where P-CABs fit in, here's a quick review of the most common medications used for managing GERD.

Acid buffers (Tums, Rolaids) help temporarily neutralize stomach acid. They're inexpensive, available without a prescription, and great for occasional heartburn. However, they don't reduce the amount of acid your body makes, so they're not as useful for frequent or severe GERD.

H2 blockers, such as famotidine (Pepcid) and cimetidine (Tagamet), work by blocking signals that trigger your stomach to produce acid. Available in both over-the-counter and prescription strengths, they're more effective than antacids for regular symptoms and can be taken before meals to prevent heartburn. However, the body can build up a tolerance to them over time.

Proton-pump inhibitors (PPIs), including omeprazole (Prilosec) and esomeprazole (Nexium), are the most commonly prescribed GERD medications. They reduce stomach acidity by directly blocking proteins in your stomach lining that "pump" hydrogen ions into your stomach to boost its acid levels. PPIs are often the go-to choice for people with frequent symptoms.

But PPIs don't act immediately, sometimes taking a few days before reaching peak effects. "They also need to be activated by stomach acid, so you have to take them 30 to 60 minutes before eating," explains Dr. Friedman. "That can be inconvenient, and people sometimes forget to take them."

Additionally, PPIs may cause stomach upset and diarrhea. And long-term PPI use may increase your risk of bone fractures, kidney disease, and nutrient deficiencies - so you should use them at the lowest effective dose and for short periods, says Dr. Friedman. "You might go on and off them, and switch between them and other medications."

What makes P-CABs different

P-CABs work similarly to PPIs in that they block acid-producing pumps in the stomach, but they do it slightly differently: Rather than needing to be activated by stomach acid first, P-CABs block a key molecule (potassium) that the pump needs to function. This means they can be taken with or without food.

P-CABs also work more quickly than PPIs to suppress stomach acid, reaching their peak action within the first day of use. And because the effect is long-lasting, P-CABs can provide more consistent acid control throughout the day and night.

Side effects with P-CABs "appear to be similar to those seen with PPI drugs," says Dr. Friedman. But since these new drugs don't yet have the long-term safety records of more established ones, he says, some clinicians "might take a 'wait and see' attitude before prescribing them."

Right now, one of the biggest barriers to using P-CABs is their cost, he adds, since newer medications aren't always covered by health insurance. "But if all else were equal, it would be a good option for many people," he says.

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