Severe Erosive Esophagitis: Vonoprazan or Standard-Dose PPI
At LA Grade C/D severity, vonoprazan's own healing-rate data pulls ahead of standard-dose PPI therapy in a way it doesn't at milder grades — a real question of whether to reach for it now or start where the guidelines have started for decades.
Daniel P., 58, has spent the past year adjusting to life in a smaller house after his divorce finalized, cooking almost exclusively for himself for the first time in three decades — heavier on the fried and reheated meals than he'd like to admit, and it shows in the fifteen pounds he's gained since. He described three months of a burning sensation that had gone from “after big meals” to “most nights, whether I eat or not,” and one episode two weeks ago where solid food genuinely felt like it was catching on the way down. Endoscopy showed confluent mucosal breaks involving more than 75% of the esophageal circumference — LA Grade D, the most severe category on the classification, with a small area of exposed submucosa but no active bleeding.
Grade D changes the calculus in a way milder grades don't. In the head-to-head trial data comparing vonoprazan to standard-dose PPI therapy for erosive esophagitis, the two perform comparably at lower grades, but vonoprazan's healing rate pulls measurably ahead specifically at LA Grade C and D severity — the population his own endoscopy places him squarely inside. That's the actual argument for reaching past the drug class every prior GERD workup of his has started with, rather than treating vonoprazan as a second-line option to try only if standard therapy underperforms. In Laine and colleagues' randomized comparison of vonoprazan against lansoprazole, 92% of Grade C/D patients had healed by week 8 on vonoprazan against 72% on the PPI — a twenty-point gap in the exact severity band his endoscopy places him in, against no meaningful separation at all in Grade A/B disease. His coverage for the newer agent was confirmed before the plan was finalized, which removes the one practical objection that would otherwise have settled this on cost alone.
Reaching past the usual first step
This is Grade D, not Grade A or B, and that distinction matters for which drug I'd reach for. The trial data comparing vonoprazan to standard-dose PPI therapy shows comparable healing at milder grades, but at C and D specifically, vonoprazan pulls ahead on healing rate — and that's exactly the severity band his endoscopy places him in today. I'd start there rather than treat it as a step-up option.
I'm not disputing the severity-stratified data. What I want on the table is that standard-dose PPI therapy still heals the substantial majority of Grade D esophagitis, and vonoprazan carries a real cost and access barrier that a standard PPI doesn't — his coverage status isn't confirmed yet.
The healing-rate advantage at this severity is real, but I'd want to know it clears a meaningful clinical threshold, not just a statistical one, before treating access cost as secondary.
Whichever of you wins the induction argument, I want to name something neither of you has addressed yet: relapse after healing at this severity is common no matter which drug got him there. If we induce remission and don't plan maintenance therapy explicitly today, we're likely back here in six months regardless of which acid suppressant did the initial work. I'd support starting vonoprazan given the severity-matched data, but only alongside a stated maintenance plan, not as a decision to revisit later once he already feels better.
Agreed: vonoprazan 20mg daily for 8 weeks, with maintenance dosing at 10mg daily already scheduled to start immediately after rather than decided at a future visit, and a confirmed repeat endoscopy at 8 weeks to document healing before any step-down is considered.