Vonoprazan for the Treatment of GERD, Erosive Esophagitis, and Eradication of H. pylori

Lilian White, MD
February 9, 2026

Vonoprazan is indicated as part of double or triple therapy for eradication of Helicobacter pylori and the treatment of gastroesophageal reflux disease (GERD) and erosive esophagitis. Vonoprazan suppresses gastric acid secretion, similar to proton pump inhibitors (PPIs), but by inhibiting the H+, K+-ATPase enzyme.

Testing for H. pylori infection in patients with GERD is not recommended by the American College of Gastroenterology unless symptoms of peptic ulcer disease or dyspepsia are present. Other indications for testing for H. pylori include having unexplained iron deficiency anemia, before initiation of long-term nonsteroidal anti-inflammatory treatment, and idiopathic thrombocytopenic purpura in adults, in addition to those with household contacts positive for H. pylori infection. Patients who test positive for H. pylori should be offered treatment.

Dual therapy for treatment of H. pylori includes vonoprazan, 20 mg twice daily, and amoxicillin, 1,000 mg three times daily, for 14 days. Triple therapy includes 20 mg of vonoprazan, 1000 mg of amoxicillin, and 500 mg of clarithromycin, each taken twice daily for 14 days. Dual and triple therapy have similar effectiveness in patients with H. pylori infection that is sensitive to clarithromycin. Dual therapy with vonoprazan was found to be more effective than triple therapy in one study for clarithromycin-resistant strains of H. pylori.

Vonoprazan for GERD without esophagitis is dosed at 10 mg daily for 4 weeks. For erosive esophagitis, 20 mg of vonoprazan daily for 8 weeks is recommended; 10 mg may be continued daily for 6 months for maintenance treatment.

A POEM (Patient-Oriented Evidence That Matters) published in American Family Physician (AFP) in 2025 reported that vonoprazan is not more effective than more cost-effective PPIs for the prevention and treatment of peptic ulcers.

A 2026 STEPS (Safety, Tolerability, Effectiveness, Price, Simplicity) piece in AFP noted a number needed to treat (NNT) of 9 in one study for patients with H. pylori infection treated with triple therapy with vonoprazan vs lansoprazole. An even lower NNT of 3 was found for patients with H. pylori infection resistant to treatment with clarithromycin. Nearly 20% of H. pylori strains in the United States are resistant to clarithromycin, and vonoprazan may be a reasonable first-line treatment.

Adverse effects of vonoprazan are similar to PPIs and include increased risk of nutrient deficiencies (namely, vitamin B₁₂, magnesium, potassium, calcium), pneumonia, Clostridium difficile diarrhea, and osteoporotic fractures. Initial and periodic monitoring for these nutrient deficiencies is recommended in patients receiving long-term treatment. Safety during pregnancy and while breastfeeding has not been established. A registry is available for those taking vonoprazan who are pregnant. Dosage adjustments are recommended in patients with renal or hepatic impairment. Overall, vonoprazan is generally well tolerated without adverse effects prompting discontinuation, similar to PPIs, but with a higher cost. Vonoprazan is approximately $185 for a 2-week course of treatment at the 20 mg dose, around 10 times the cost of generic lansoprazole.