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Clinical Practice Update

Integrating potassium-competitive acid blockers into clinical practice

Find out when to use potassium-competitive acid blockers (P-CABs) in the clinical management of foregut disorders, specifically GERD, H. pylori infection and peptic ulcer disease.

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Best practice advice

  1. Based on nonclinical factors (including cost, greater obstacles to obtaining medication, and fewer long-term safety data), clinicians should generally not use P-CABs as initial therapy for acid-related conditions in which clinical superiority has not been shown. 
  2. Based on current costs in the United States, even modest clinical superiority of P-CABs over double-dose proton pump inhibitors may not make P-CABs cost-effective as first-line therapy. 
  3. Clinicians should generally not use P-CABs as first-line therapy for patients with uninvestigated heartburn symptoms or nonerosive reflux disease. Clinicians may use P-CABs in selected patients with documented acid-related reflux who fail therapy with twice-daily PPIs. 
  4. Although there is currently insufficient evidence for clinicians to use P-CABs as first-line on-demand therapy for patients with heartburn symptoms who have previously responded to antisecretory therapy, their rapid onset of acid inhibition raises the possibility of their utility in this population. 
  5. Clinicians should generally not use P-CABs as first-line therapy in patients with milder erosive esophagitis (Los Angeles classification of erosive esophagitis grade A/B EE). Clinicians may use P-CABs in selected patients with documented acid-related reflux who fail therapy with twice-daily PPIs. 
  6. Clinicians may use P-CABs as a therapeutic option for the healing and maintenance of healing in patients with more severe EE (Los Angeles classification of erosive esophagitis grade C/D EE). However, given the markedly higher costs of the P-CAB presently available in the United States and the lack of randomized comparisons with double-dose PPIs, it is not clear that the benefits in endoscopic outcomes over standard-dose PPIs justify the routine use of P-CABs as first-line therapy. 
  7. Clinicians should use P-CABs in place of PPIs in eradication regimens for most patients with H pylori infection. 
  8. Clinicians should generally not use P-CABs as first-line therapy in the treatment or prophylaxis of peptic ulcer disease. 
  9. Although there is currently insufficient evidence for clinicians to use P-CABs as first-line therapy in patients with bleeding gastroduodenal ulcers and high-risk stigmata, their rapid and potent acid inhibition raises the possibility of their utility in this population. 

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