What is the recommended daily dose of vonoprazan for an adult with normal hepatic and renal function?

Vonoprazan 20 mg Daily Dosing

For adults with normal hepatic and renal function, vonoprazan 20 mg once daily is the standard dose for healing erosive esophagitis (8 weeks), treating gastric ulcers (8 weeks), and duodenal ulcers (6 weeks). 1

Standard Dosing by Indication

Erosive Esophagitis

• Healing phase: Vonoprazan 20 mg once daily for 8 weeks achieves healing rates of approximately 94%, demonstrating noninferiority to lansoprazole 30 mg 2, 1
• Maintenance phase: Reduce to 10 mg once daily for up to 6 months after healing is achieved 1

Peptic Ulcer Disease

• Gastric ulcers: Vonoprazan 20 mg once daily for 8 weeks achieves 94% healing rates 2
• Duodenal ulcers: Vonoprazan 20 mg once daily for 6 weeks achieves 96-98% healing rates 2
• Ulcer prophylaxis (in patients on NSAIDs/aspirin with ulcer history): Vonoprazan 10-20 mg once daily prevents recurrence with rates of 0.5-1.5% 2

Non-Erosive Reflux Disease (NERD)

• Vonoprazan 10 mg once daily for 4 weeks, though clinical trial data show inconsistent results and the American Gastroenterological Association does not recommend it as first-line therapy 3, 1

H. pylori Eradication

Triple therapy (first-line):

• Vonoprazan 20 mg twice daily + amoxicillin 1,000 mg twice daily + clarithromycin 500 mg twice daily for 14 days 1
• This achieves 92% eradication rates versus 80% with PPI-based therapy 2
• In clarithromycin-resistant strains, eradication rates are 66-70% versus only 32% with PPIs 2

Dual therapy (alternative):

• Vonoprazan 20 mg twice daily + amoxicillin 1,000 mg three times daily for 14 days 1
• Recent data shows amoxicillin 1,000 mg three times daily for 10 days achieves 91.2% eradication rates 4

High-Risk Bleeding Ulcers

• Vonoprazan 20 mg twice daily for 3 days, then 20 mg once daily for 28 days after endoscopic hemostasis 2
• This achieves rebleeding rates of 7.1% versus 10.4% with IV pantoprazole infusion 2

Administration Guidelines

• Take with or without food (food has minimal effect on absorption) 1, 5
• Swallow tablets whole; do not chew or crush 1
• Missed dose management for once-daily dosing: Take within 12 hours of missed dose; if >12 hours have passed, skip and resume normal schedule 1
• Missed dose management for H. pylori treatment: Take within 4 hours of missed dose; if >4 hours have passed, skip and resume normal schedule 1

Clinical Positioning Algorithm

The American Gastroenterological Association recommends against using vonoprazan as first-line therapy for conditions where PPIs are equally effective but significantly less expensive (mild erosive esophagitis, NERD, peptic ulcer disease) 3

Consider vonoprazan 20 mg daily when:

1. Patient fails twice-daily PPI therapy for GERD 3
2. Severe erosive esophagitis (LA grade C/D) requiring maintenance therapy 3
3. H. pylori eradication, particularly with clarithromycin resistance 2, 6
4. High-risk bleeding ulcers requiring potent acid suppression 2

Important Caveats

• Cost considerations: Vonoprazan is significantly more expensive than standard and double-dose PPIs in the United States, limiting its use as first-line therapy 3
• CYP2C19 independence: Unlike PPIs, vonoprazan is not affected by CYP2C19 polymorphisms, providing more consistent acid suppression across patient populations 6, 5
• Long-term safety: While short-term safety appears comparable to PPIs, long-term safety data are more limited 3
• Contraindications: Do not use with rilpivirine-containing products or in patients with known hypersensitivity to vonoprazan 1
• Drug interactions: When co-administered with clarithromycin, vonoprazan AUC increases 1.8-fold due to mutual metabolic inhibition 5