What is the initial treatment for esophagitis, particularly that caused by Gastroesophageal Reflux Disease (GERD)?

From the Guidelines

The initial treatment for esophagitis caused by GERD should focus on acid suppression with proton pump inhibitors (PPIs), starting with a standard-dose PPI once daily, taken 30-60 minutes before breakfast for optimal effect, as recommended by the American College of Physicians 1. This approach is supported by the clinical guidelines committee of the American College of Physicians, which suggests that in most patients with typical GERD symptoms, an initial trial of empirical acid-suppressive therapy with once-daily PPIs is warranted and endoscopy is not indicated 1. The following PPIs may be used: dexlansoprazole, esomeprazole, lansoprazole, omeprazole, pantoprazole, or rabeprazole, as their absolute differences in efficacy for symptom control and tissue healing are small 1. Some key points to consider when treating esophagitis caused by GERD include:

• Starting with a standard-dose PPI, such as omeprazole 20mg, esomeprazole 40mg, pantoprazole 40mg, or lansoprazole 30mg once daily 1
• Taking the PPI 30-60 minutes before breakfast for optimal effect 1
• Continuing the initial treatment for 8 weeks 1
• Implementing lifestyle modifications simultaneously, including elevating the head of the bed, avoiding meals within 3 hours of bedtime, eliminating trigger foods, weight loss if overweight, and smoking cessation
• Considering additional treatments, such as H2-receptor antagonists or antacids, for breakthrough symptoms
• Evaluating the need for maintenance therapy or further testing after the initial 8-week treatment 1. It's also important to note that antireflux surgery may be considered in certain cases, such as patients with esophagitis who are intolerant of PPIs or have persistent troublesome regurgitation, but this should be balanced with a thorough discussion of potential post–antireflux surgery symptoms 1.

From the FDA Drug Label

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 Omeprazole delayed-release capsules are indicated for the treatment of heartburn and other symptoms associated with GERD for up to 4 weeks in patients 2 years of age and older. The initial treatment for esophagitis, particularly that caused by Gastroesophageal Reflux Disease (GERD), is omeprazole delayed-release capsules for 4 to 8 weeks. Key points to consider:

• The treatment duration may be extended to another 4 weeks if needed.
• Omeprazole is a proton pump inhibitor (PPI) that reduces the amount of acid in the stomach.
• It is essential to follow the prescribed dosage and treatment duration to ensure effective treatment and minimize potential side effects 2 2.

From the Research

Initial Treatment for Esophagitis Caused by Gastroesophageal Reflux Disease (GERD)

The initial treatment for esophagitis, particularly that caused by GERD, typically involves the use of proton pump inhibitors (PPIs) 3, 4.

• PPIs are considered the medical treatment of choice for GERD, as they effectively reduce stomach acid production and allow the esophagus to heal.
• Studies have shown that PPIs can heal severe reflux esophagitis and improve GERD symptoms, regardless of whether they are taken in the morning or at night 5.
• The aim of PPI therapy is to use the lowest effective dose, usually starting with a full-dose regimen such as omeprazole 20 mg once daily 4.

Alternative Treatment Options

In cases where standard-dose PPIs are not effective, alternative treatment options may be considered, including:

• Modification of lifestyle with PPI therapy
• Switching to another PPI
• Changing the administration method (e.g., taking PPIs before meals)
• Double-dose PPI (in divided doses) 6
• Vonoprazan, a potassium-competitive acid blocker, which has been shown to be effective for initial and maintenance therapy in reflux esophagitis, nonerosive esophagitis, and PPI-resistant GERD 7

Treatment Strategy

The treatment strategy for esophagitis caused by GERD may involve a combination of lifestyle modifications, medication, and surgery 4.

• Lifestyle changes, such as weight loss and smoking cessation, can be beneficial in managing GERD symptoms.
• Medication with PPIs is the most common treatment, and surgery with laparoscopic fundoplication may be considered in select patients.
• New endoscopic and less invasive surgical procedures are emerging, which may reduce the use of long-term PPI and fundoplication, but their long-term safety and efficacy remain to be scientifically established 4.