What is the appropriate management of erosive esophagitis and dyspepsia in a patient who declines proton‑pump inhibitor therapy?

Management of Erosive Esophagitis and Dyspepsia When Patient Declines PPI Therapy

If a patient with erosive esophagitis declines PPI therapy, you should strongly recommend potassium-competitive acid blockers (P-CABs) as the first-line alternative, particularly vonoprazan or zastaprazan, which demonstrate superior or equivalent efficacy to PPIs for healing erosive esophagitis. 1, 2

Critical Context: Severity Determines Necessity

Before accepting PPI/P-CAB refusal, you must determine erosive esophagitis severity:

• Los Angeles Grade C/D (severe) erosive esophagitis: These patients should generally NOT discontinue acid suppression therapy due to high risk of complications including GI bleeding, stricture formation, and Barrett's esophagus development 3
• Los Angeles Grade A/B (mild-moderate): More flexibility exists, though acid suppression remains strongly recommended

Primary Alternative: Potassium-Competitive Acid Blockers (P-CABs)

P-CABs represent the most effective non-PPI option:

Specific P-CAB Options:

• Vonoprazan 20 mg daily: Ranked highest for initial treatment (P-score = 0.68) and maintenance (P-score = 0.94) 1
• Zastaprazan 20 mg daily: Demonstrated significantly better healing than vonoprazan at 8 weeks (RR 1.10) 4
• Tegoprazan, keverprazan, fexuprazan: Also effective alternatives 1, 2

P-CAB Advantages:

• Superior healing rates in severe EE (Grade C/D): RR = 1.10 compared to PPIs 1
• Lower recurrence risk during maintenance: RR = 0.59 1
• Particularly effective in PPI-resistant cases: 88% improvement rate, 42% complete resolution 5
• Rapid onset with sustained acid suppression 2

Secondary Alternatives (Less Effective)

If P-CABs are also declined or unavailable:

H2 Receptor Antagonists

• Limited efficacy for erosive esophagitis healing compared to PPIs/P-CABs 6
• May be used as adjunctive nighttime therapy but insufficient as monotherapy for EE 7

Sucralfate (Venter)

• Showed effectiveness in healing multiple erosions in patients who failed 4-week standard therapy 8
• Requires 2-week treatment course
• Historically used but less evidence than modern therapies

Alginates

• Not indicated for long-term use 3
• May provide symptomatic relief for breakthrough symptoms only 7
• Insufficient for healing erosive esophagitis 6

Management Algorithm for PPI-Declining Patients

Step 1: Assess Disease Severity

• Perform or review endoscopy with Los Angeles classification
• Document hiatal hernia presence and size
• Grade any Barrett's esophagus if present 7

Step 2: Risk Stratification

• High-risk (LA Grade C/D, history of complications, Barrett's esophagus): Strongly counsel that acid suppression is medically necessary; document refusal if patient persists 3
• Lower-risk (LA Grade A/B, no complications): Proceed with alternative therapy

Step 3: Initiate P-CAB Therapy

• First choice: Vonoprazan 20 mg daily or zastaprazan 20 mg daily
• Alternative: Tegoprazan, keverprazan, or fexuprazan per availability 1, 2

Step 4: Adjunctive Measures

• Weight management if BMI elevated
• Dietary modifications (avoid trigger foods, late meals)
• Elevate head of bed
• Avoid tight clothing 7

Step 5: Follow-up Strategy

• Reassess symptoms at 4-8 weeks
• If inadequate response: Perform pH-impedance monitoring to confirm GERD phenotype 7
• If healing achieved: Continue maintenance therapy (P-CABs show lower recurrence rates than PPIs) 1

Critical Pitfalls to Avoid

1. Do not accept therapy refusal in severe EE without extensive counseling: Patients with LA Grade C/D have high complication risk including bleeding and stricture 3

2. Do not use alginates or H2RAs as monotherapy for erosive esophagitis: These have limited healing efficacy and are not appropriate first-line alternatives 6

3. Do not assume functional dyspepsia without objective testing: If patient has dyspepsia without proven erosive esophagitis, perform endoscopy before committing to long-term therapy 7

4. Do not continue ineffective therapy: If P-CAB fails after 8 weeks, perform pH monitoring off medication to confirm diagnosis and consider referral for anti-reflux procedures 7

For Functional Dyspepsia Component

If dyspepsia persists without erosive disease:

• Tegoprazan specifically offers effective symptom relief without delaying gastric emptying 2
• Consider neuromodulation (tricyclic antidepressants, SNRIs) if functional overlay present 7
• Refer for cognitive behavioral therapy or hypnotherapy for refractory symptoms 7

Documentation Requirements

Document clearly:

• Severity of erosive esophagitis (LA classification)
• Specific reasons for PPI refusal
• Discussion of risks of untreated severe EE
• Alternative therapy plan with P-CABs
• Follow-up schedule for reassessment

The bottom line: P-CABs, particularly vonoprazan or zastaprazan, are the evidence-based alternative when patients decline PPIs, but severe erosive esophagitis (LA Grade C/D) requires aggressive counseling about the medical necessity of acid suppression therapy regardless of patient preference.