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Acid-related diseases (ARDs), such as peptic ulcers and gastroesophageal reflux disease, represent a major health-care concern. Some major milestones in our understanding of gastric acid secretion and ARD treatment reached during the last 50years include 1) discovery of histamine H-receptors and development of H-receptor antagonists, 2) identification of H,K-ATPase as the parietal cell proton pump and development of proton pump inhibitors (PPIs), and 3) identification of Helicobacter pylori (H. pylori) as the major cause of peptic ulcers and development of effective eradication regimens. Although PPI treatments have been effective and successful, there are limitations to their efficacy and usage, i.e. short half-life, insufficient acid suppression, slow onset of action, and large variation in efficacy among patients due to CYP2C19 metabolism. Potassium-competitive acid blockers (P-CABs) inhibit H,K-ATPase in a reversible and K-competitive manner, and exhibit almost complete inhibition of gastric acid secretion from the first dose. Many pharmaceutical companies have tried to develop P-CABs, but most of their clinical development has been discontinued due to safety concerns or a similar efficacy to PPIs. Revaprazan was developed in Korea and was the first P-CAB approved for sale. Vonoprazan, approved in 2014 in Japan, has a completely different chemical structure and higher pKa value compared to other P-CABs, and exhibits rapid onset of action and prolonged control of intragastric acidity. Vonoprazan is an effective treatment for ARDs that is especially effective in healing reflux esophagitis and for H. pylori eradication. P-CABs, such as vonoprazan, promise to further improve the management of ARDs.

This review project, including the publication of this article, was funded by Takeda Pharmaceutical Company Limited.

We elucidated efferent projections of second-order relay neurons (P-cells) activated by afferents originating from slowly adapting pulmonary receptors (SARs) to determine the central pathway of the SAR-evoked reflexes. Special attention was paid to visualizing the P-cell projections within the nucleus tractus solitarii (NTS), which may correspond to the inhibitory pathway from P-cells to second-order relay neurons (RAR-cells) of rapidly adapting pulmonary receptors. P-cells were recorded from the NTS in Nembutal-anesthetized, paralyzed, and artificially ventilated rats. First, we used electrophysiological methods of antidromic mapping and showed that the majority of the P-cells examined projected their axons to the caudal NTS and to the dorsolateral pons corresponding to the parabrachial complex. Second, a mixture of HRP and Neurobiotin was injected intracellularly or juxtramembranously into P-cells. (1) Stained P-cells (n = 7) were located laterally to the solitary tract and had dendrites extending characteristically along the lateral border of the solitary tract. (2) All P-cells had stem axons projecting to the ipsilateral medulla. Of these, the axons from five P-cells projected to the nucleus ambiguus and its vicinity with distributing boutons. Some of these axons further ascended in the ventrolateral medulla, and distributed boutons in the areas ventral or ventrolateral to the nucleus ambiguus. (3) All the P-cells had axonal branches with boutons in the NTS area. In particular, axons from three P-cells projected bilaterally to the medial NTS caudal to the obex, i.e., to the area of RAR-cells. These results show anatomic substrates for the connections implicated in the P-cell inhibition of RAR-cells as well as the SAR-induced respiratory reflexes.

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