What is the recommended dose of vonoprazan (potassium-competitive acid blocker) for a patient with peptic ulcer disease, particularly those with a history of Helicobacter pylori infection or impaired renal function?

Vonoprazan Dosing for Peptic Ulcer Disease

For peptic ulcer disease, vonoprazan 20 mg once daily for 8 weeks (gastric ulcers) or 6 weeks (duodenal ulcers) is the recommended dose, achieving healing rates of approximately 94-96%. 1, 2

Standard Dosing by Ulcer Type

Gastric Ulcers

• Vonoprazan 20 mg once daily for 8 weeks achieves healing rates of 94%, demonstrating noninferiority to lansoprazole 30 mg 3, 1, 2

Duodenal Ulcers

• Vonoprazan 20 mg once daily for 6 weeks achieves healing rates of 96-98%, comparable to lansoprazole 30 mg 1, 2

Dosing for H. pylori-Associated Ulcers

If H. pylori infection is present, eradication therapy should be initiated immediately, as this is the definitive treatment for H. pylori-associated ulcers. 1

Triple Therapy (Preferred)

• Vonoprazan 20 mg twice daily + amoxicillin 1,000 mg twice daily + clarithromycin 500 mg twice daily for 14 days 3, 2
• This regimen achieves eradication rates of 92% vs 80% with PPI-based therapy 3
• In clarithromycin-resistant strains, vonoprazan provides even greater benefit (66-70% vs 32% eradication with PPIs) 3

Dual Therapy (Alternative)

• Vonoprazan 20 mg twice daily + amoxicillin 1,000 mg three times daily for 14 days 2
• This simplified regimen achieves eradication rates approaching 85-95% and eliminates the need for clarithromycin 3, 4

Dosing Adjustments for Renal Impairment

Renal function significantly impacts vonoprazan dosing for ulcer healing but not for H. pylori eradication. 2

For Ulcer Healing

• eGFR ≥30 mL/min: 20 mg once daily 2
• eGFR <30 mL/min: 10 mg once daily (due to 2.4-fold increase in drug exposure) 2, 5

For H. pylori Eradication

• eGFR ≥30 mL/min: 20 mg twice daily 2
• eGFR <30 mL/min: Use is not recommended 2

Dosing Adjustments for Hepatic Impairment

Hepatic dysfunction requires dose reduction for ulcer healing but contraindicates use in moderate-severe impairment for H. pylori treatment. 2

For Ulcer Healing

• Child-Pugh Class A: 20 mg once daily 2
• Child-Pugh Class B or C: 10 mg once daily (due to 2.6-fold increase in drug exposure) 2, 5

For H. pylori Eradication

• Child-Pugh Class A: 20 mg twice daily 2
• Child-Pugh Class B or C: Use is not recommended 2

Ulcer Prophylaxis Dosing (Secondary Prevention)

For patients with ulcer history requiring long-term NSAIDs or aspirin, vonoprazan 10-20 mg once daily is noninferior to lansoprazole 15 mg. 3, 6

• Vonoprazan 10 mg or 20 mg once daily prevents ulcer recurrence in patients on chronic aspirin (recurrence rates 0.5-1.5% vs 2.8% with lansoprazole) 3, 7
• For NSAID users with ulcer history, vonoprazan 10-20 mg achieves recurrence rates of 3-6% vs 6-8% with lansoprazole 3

High-Risk Bleeding Ulcers

For bleeding ulcers with high-risk stigmata after endoscopic hemostasis, vonoprazan 20 mg twice daily for 3 days, then 20 mg once daily for 28 days is noninferior to high-dose IV PPI. 3

• This regimen achieves rebleeding rates of 7.1% vs 10.4% with IV pantoprazole infusion 3
• The rapid and potent acid inhibition of vonoprazan makes it particularly suitable for this indication 3

Critical Clinical Considerations

When NOT to Use Vonoprazan First-Line

• Vonoprazan should generally not be used as first-line therapy for routine peptic ulcers due to significantly higher costs compared to PPIs and lack of clear superiority in most cases 3, 6
• Reserve vonoprazan for PPI failures or specific high-risk scenarios 6

Ulcer Etiology Matters

• H. pylori-associated ulcers respond better to vonoprazan than idiopathic or NSAID-related ulcers 1, 6
• Always test for H. pylori and initiate eradication therapy when positive 1

Common Pitfalls to Avoid

• Do not discontinue therapy prematurely—gastric ulcers require the full 8 weeks, duodenal ulcers require 6 weeks 1, 2
• Do not overlook renal/hepatic dose adjustments—failure to reduce doses in impaired patients increases adverse event risk 2
• Do not assume all ulcers are acid-related—if ulcers fail to heal despite adequate acid suppression, consider malignancy, infection (other than H. pylori), or vasculitis 2

Administration Details

• Vonoprazan can be taken with or without food (unlike PPIs which require fasting) 2
• Swallow tablets whole; do not crush or chew 2
• If a dose is missed, take within 12 hours for once-daily dosing or within 4 hours for twice-daily H. pylori regimens 2