Acid suppressants during hospitalization and after discharge in patients after gastroduodenal ESD

Abstract

We read with great interest the study by Abe et al. [1]. The report compared the rate of delayed bleeding stratified by upper gastrointestinal endoscopic procedures between vonoprazan and proton pump inhibitor (PPI) treated individuals. Vonoprazan reduced the odds of delayed bleeding by approximately 30% after gastroduodenal endoscopic submucosal dissection (ESD). To add to their work, we discuss the use of acid suppressants during hospitalization and after discharge, and clinical management of patients after gastroduodenal ESD. Vonoprazan is fast acting and acid-stable [2]. However, the lack of knowledge about advantages of vonoprazan led to discontinuation of its use post-discharge and a shift to PPIs instead. Recently, we analyzed the short-term (during hospitalization) and late (after discharge) bleeding rates between vonoprazan and PPI treatments using our data [3]. Vonoprazan was associated with lower bleeding rates after gastric ESD, which corroborates the findings of Abe et al. [1]. When the time of discharge was assumed to be postoperative day 5 or 7, vonoprazan was associated with a significantly reduced risk of bleeding after discharge (day 5: 2.2% vs. 4.8%, P = 0.014; day 7, 1.1% vs. 2.9%, P = 0.026). Our results may be related to the characteristics of vonoprazan—strong and long-lasting— and its pharmacokinetics, which are not affected by CYP polymorphisms. Other factors such as fasting duration after gastroduodenal ESD, recommended acid suppressants during fasting (vonoprazan orally or PPI injection), and second endoscopic evaluation are not discussed in the original article. Fasting after the procedure (days 0 to 1) is customary in Japan, but further discussion may be needed to generalize findings in Western countries, where short-term hospitalization is common. PPI injection is administered during fasting and such cases were included in our study; however, they were excluded from this study. In our study, the performance of the second endoscopic evaluation was balanced between the two groups, and the second endoscopy was not an independent factor to reduce bleeding in our Cox regression analysis (adjusted hazard ratio: 1.32, 95% confidence interval 0.86–1.88). There is, however, a possibility that second endoscopic evaluation was performed more frequently in high-risk cases of bleeding. We believe that randomized-controlled trials comparing vonoprazan to PPIs are required to clarify suggestions in the original article by balancing management strategies after gastroduodenal ESD between the groups. In conclusion, these discussions support the article of Abe et al. [1], regarding the clinical management of patients after gastroduodenal ESD. Vonoprazan may need to be continued during hospitalization and after discharge.