DAY2 - Are PPIs sufficient in clinical medicine and PCABs not needed?

Loren Laine, MD, from Yale University School of Medicine in New Haven, Connecticut, took the position the PPIs are sufficient in clinical medicine, and PCABs are not needed. He noted that evidence from various trials and meta-analyses show no difference in intragastric acid inhibition with PCABs vs. esomeprazole once daily PPI (see Zhuang et al. Am J Gastroenterol. 2024). PCAB might be reserved for LA C/D erosive esophagitis and in most patients with H. pylori. However, dual therapy with PPI vs PCABs has been shown to be non-inferior for H. pylori eradication and increasing the PPI dose may be sufficient. The available safety data for PPIs and PCABs are similar, but the higher gastrin levels with PCABs could increase the risk of colon and gastric cancer. The cost of PCABs ($700) is much higher than PPIs ($30-40), which introduces inequity in access for those without insurance coverage. Dr. Laine concluded that there is no reason to use a non-inferior medication, especially one that is higher cost than PPIs.

Paul Moayyedi, MD, PhD, from McMaster University in Ancaster, Ontario, Canada, took the opposing view, that PPIs are not sufficient in clinical medicine and PCABs are needed in certain patients. He cited Patel et al. (Gastroenterology. 2025) as the current guideline, and noted that PPIs cause irreversible inhibition whereas PCABs are better at reducing pH. He agreed that PCABs are particularly important for H. pylori eradication in patients who fail on quadruple therapy to prevent recurrence in those with a family history of gastric cancer, peptic ulcer, or gastric MALT. Patients with erosive esophagitis would also benefit from PCABs over PPIs. He recognized the concern about gastrin increase, but if PCABs are used for patients with severe disease, the benefit outweighs the risk. Doubling the dose of PPIs to twice daily has not shown improvement over once daily, so there needs to be an alternative option. In addition, PCABs carry a lower risk of bleeding than PPIs. Treatment is only needed for a few weeks, so the cost issue is limited. 
Audience polling revealed that 60% felt PCABs are needed and 40% felt that PPIs are sufficient.