Limit use of Voquezna for H. pylori

Think of vonoprazan as a "fancy PPI", with some differences. For instance, PPIs block active proton pumps, vonoprazan blocks both active.....

As a community pharmacist, you should be updated. Voquezna Dual Pak and Triple Pak will be new prescribed combos for treating H. pylori. These combos contain vonoprazan, the first potassium-competitive acid blocker (PCAB)...

Think of vonoprazan as a "fancy PPI", with some differences. For instance, PPIs block active proton pumps, vonoprazan blocks both active and resting proton pumps. That’s why it can take a few days for PPIs to kick in, and most need to be taken 30 to 60 min before a meal. Vonoprazan starts working within hours, and can be taken at any time.

Vonoprazan will be co-packaged with amoxicillin in Voquezna Dual Pak or amoxicillin and clarithromycin in the Triple Pak. Both Voquezna packs will be touted to work at least as well as triple therapy with a PPI, amoxicillin, and clarithromycin. But clarithromycin-based therapies have fallen out of favor due to growing resistance and lower efficacy. Overall, eradication rates with Voquezna Dual OR Triple Pak are about 80%, and with resistance, they can fall to around 65%. Don’t jump to Voquezna to treat H. pylori. There’s no proof it’s more effective than quadruple therapies, which have eradication rates of 80% to 90%. Plus Add also the high cost of this drug for 14 days, other regimens can cost much less. And it still requires multiple pills, multiple times/day.

Usually prescribe bismuth quadruple therapy (PPI, bismuth, metronidazole, tetracycline) first, especially in patients with a true penicillin allergy or prior macrolide use. Consider other regimens if needed due to cost, pill burden, etc. For example, think about concomitant quadruple therapy (PPI, amoxicillin, metronidazole, clarithromycin) or triple therapy with a PPI, amoxicillin, and rifabutin. Expect to hear interest in vonoprazan for other GI uses, such as erosive esophagitis. But studies are ongoing to evaluate whether long-term risks are similar to PPIs (C. diff, fractures, etc). For more data, read our note, "Peptic ulcer: assessment and management"

REFERENCES

Chey WD, Mégraud F, Laine L, López LJ, Hunt BJ, Howden CW. Vonoprazan Triple and Dual Therapy for Helicobacter pylori Infection in the United States and Europe: Randomized Clinical Trial. Gastroenterology. 2022 Sep;163(3):608-619. Available at: https://pubmed.ncbi.nlm.nih.gov/35679950

Shah SC, Iyer PG, Moss SF. AGA Clinical Practice Update on the Management of Refractory Helicobacter pylori Infection: Expert Review. Gastroenterology. 2021 Apr;160(5):1831-1841. Available at: https://pubmed.ncbi.nlm.nih.gov/33524402

Chey WD, Leontiadis GI, Howden CW, Moss SF. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2017 Feb;112(2):212-239. Available at: https://pubmed.ncbi.nlm.nih.gov/28071659