Introduction:
This study compared the early symptom relief efficacy and safety of vonoprazan, a potassium-competitive acid blocker (P-CAB), and esomeprazole, a proton pump inhibitor (PPI), in patients with erosive esophagitis (EE). While PPIs are established treatments, P-CABs are a new option offering a faster onset of action.

Material and methods:
In this multicenter, double-blind, randomized controlled trial, adults with Gastroesophageal Reflux Disease Questionnaire (GerdQ) scores ≥8 and endoscopy-confirmed EE received either vonoprazan 20 mg or esomeprazole 40 mg once daily for two weeks. The primary endpoint was complete resolution (CR) of symptoms at weeks 1 and 2 using GerdQ. Secondary endpoints included subgroup responses and safety.

Results:
Among 216 participants (vonoprazan: 111; esomeprazole: 105), most had mild EE. At week 1, CR rates were 39.6% [95% CI: 31.0–48.9%] with vonoprazan and 42.9% [95% CI: 33.8–52.4%] with esomeprazole in the intention-to-treat (ITT) analysis, and 43.1% [95% CI: 33.9–52.8%] vs. 45.9% [95% CI: 36.4–55.8%] in the per-protocol (PP) analysis. At week 2, CR rates were 60.4% [95% CI: 51.1–69.0%] vs. 61.0% [95% CI: 51.4–69.7%] in ITT, and 66.3% [95% CI: 56.7–74.8%] vs. 66.0% [95% CI: 56.1–74.6%] in PP, with no significant between-group differences. Adverse events were similar, with nasopharyngitis, gastrointestinal symptoms, and headache/dizziness being the most frequent. No serious events occurred.

Conclusions:
Vonoprazan and esomeprazole demonstrated similar efficacy and safety profiles for early symptom relief in patients with EE. Given these comparable outcomes, esomeprazole may represent a more economical initial option based on short-term medication costs. (ClinicalTrials.gov; NCT06720610).