What is the best treatment for esophagitis?

From the Guidelines

The best treatment for esophagitis is proton pump inhibitor (PPI) therapy, which is effective in inducing histological and clinical remission in patients with eosinophilic oesophagitis, as recommended by the British Society of Gastroenterology (BSG) and British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) joint consensus guidelines 1.

Treatment Options

• For acid reflux-related esophagitis, lifestyle modifications are essential, including:
  • Elevating the head of the bed 6-8 inches
  • Avoiding eating 2-3 hours before bedtime
  • Eliminating trigger foods (spicy, fatty, acidic)
  • Quitting smoking
  • Maintaining a healthy weight
• H2 blockers like famotidine (20mg twice daily) may be used as alternatives or supplements to PPIs
• For severe cases, sucralfate (1g four times daily) can coat and protect the esophageal lining
• Infectious esophagitis requires specific antimicrobials based on the pathogen
• Eosinophilic esophagitis often responds to swallowed topical steroids like fluticasone (440-880mcg twice daily) or dietary elimination therapy

Diagnosis and Management

• The BSG and BSPGHAN joint consensus guidelines recommend that all adults undergoing endoscopy should have oesophageal biopsies taken if they have endoscopic signs associated with eosinophilic oesophagitis, or symptoms of dysphagia or food bolus obstruction, with a normal looking oesophagus 1
• The guidelines also recommend that maintenance therapy with topical steroid reduces the risk of recurrent food bolus obstruction 1
• Diagnosing and treating eosinophilic oesophagitis effectively early in its natural history may prevent long-term complications of fibrosis and strictures requiring subsequent endoscopic intervention 1

Dietary Management

• The GDG recommends commencing treatment in patients with EoE with a single modality therapy of either diet or pharmacotherapy; for most patients this will be pharmacotherapy which is easier to implement than dietary restriction that requires motivation, multiple endoscopies and support from a specialist dietitian 1
• Combination therapy of drugs and diet should be reserved for selected patients who fail monotherapy and have access to a multiprofessional team including a dietitian to follow them up and monitor response carefully 1
• Exclusive elemental diets have a limited role in eosinophilic oesophagitis, with high efficacy but low concordance rates and should be reserved for patients refractory to other treatments 1

From the FDA Drug Label

In 2 multicenter, double-blind, randomized, placebo-controlled, 12-week trials performed in the United States, ranitidine 150 mg 4 times daily was significantly more effective than placebo in healing endoscopically diagnosed erosive esophagitis and in relieving associated heartburn. The erosive esophagitis healing rates were as follows: Healed/Evaluable Placebo* n=229 Ranitidine 150 mg 4 times daily* n=215 Week 4 43/198 (22%) 96/206 (47%)† Week 8 63/176 (36%) 142/200 (71%)† Week 12 92/159 (58%) 162/192 (84%)† Omeprazole delayed-release capsules are indicated for the short-term treatment (4 to 8 weeks) of EE due to acid-mediated GERD that has been diagnosed by endoscopy in patients 2 years of age and older

The best esophagitis treatment is Ranitidine 150 mg 4 times daily or Omeprazole.

• Ranitidine has been shown to be effective in healing erosive esophagitis and relieving associated heartburn in clinical trials 2.
• Omeprazole is also indicated for the short-term treatment of EE due to acid-mediated GERD 3. Key points:
• Ranitidine 150 mg 4 times daily was significantly more effective than placebo in healing erosive esophagitis.
• Omeprazole is indicated for the short-term treatment of EE due to acid-mediated GERD.
• The choice of treatment should be based on individual patient needs and medical history.

From the Research

Esophagitis Treatment Options

• Proton pump inhibitors (PPIs) are a common treatment for esophagitis, with studies showing that twice-daily PPI dosing can lead to higher remission rates than once-daily dosing 4
• The choice of PPI may also matter, with esomeprazole showing higher rates of healing and maintenance of healing compared to lansoprazole or pantoprazole 5
• For patients with erosive esophagitis, PPI therapy can lead to resolution of dysphagia in most cases, but persistent dysphagia may indicate failed healing 6
• In cases of PPI-resistant reflux esophagitis, modification of lifestyle, switching to another PPI, or changing the administration method may be effective, as well as the use of vonoprazan, a potassium-competitive acid blocker 7

Eosinophilic Esophagitis Treatment

• Eosinophilic esophagitis (EoE) is a chronic immune-mediated inflammatory disease that can be treated with PPIs, topical steroid preparations, dietary therapy, and endoscopic dilation 8
• PPI therapy has been shown to be effective in inducing histologic response in patients with EoE, with a response rate of 41.7% compared to 13.3% for placebo 8
• Topical corticosteroid treatment has also been shown to be effective, with a histologic remission rate of 64.9% compared to 13.3% for placebo 8
• Dietary therapy, such as elemental diet or empirical food elimination, may also be effective in treating EoE, and esophageal dilation may be reserved for patients with symptomatic esophageal narrowing 8