Vonoprazan, aspirin and NSAIDs: new era in acid inhibition and gastroprotection

The ‘ No acid, no ulcer ’ dictum has dominated the pathogenesis and treatment of peptic ulcer disease for more than 100 years, and since it was proposed in 1910 by Dragutin (Carl) Schwarz (1868–1917).1 The dream of having a relatively potent and safe acid inhibitor was only realised in the mid-1970s with the marketing of cimetidine, later followed by other histamine-2 receptor antagonists (H2RA). The real breakthrough only came by the late 1980s with the introduction of proton pump inhibitors (PPI). The use of these products, particularly the PPIs, continues to increase making them some of the most commonly prescribed or bought over-the-counter agents in the world.2–4 This has added to the credibility of Schwarz’s dictum, as it is exceptional to come across a peptic ulcer that does not respond fully or partially to acid inhibition. The process of healing seems to be triggered or enhanced by the presence of a relatively acid-free medium regardless of aetiological factors: Helicobacter pylori , alcohol, aspirin, non-steroidal anti-inflammatory drugs (NSAID), or even in the case of some atypical ulcers such as those related to Crohn’s disease or malignancy.1–6 Of particular interest is the success of acid inhibitors in the healing or …