What is the recommended treatment for esophagitis?

From the Guidelines

The recommended treatment for esophagitis is proton pump inhibitors (PPIs) like omeprazole (20-40mg daily) or pantoprazole (40mg daily) for 4-8 weeks as first-line therapy for reflux esophagitis, as supported by the most recent guidelines 1.

Treatment Approach

The treatment approach for esophagitis depends on its cause, which can be reflux, infectious, or eosinophilic. For reflux esophagitis, PPIs are the first line of treatment.

• For immediate symptom relief, antacids or H2 blockers like famotidine (20mg twice daily) can be used.
• Lifestyle modifications are essential and include elevating the head of the bed 6-8 inches, avoiding meals 2-3 hours before bedtime, eliminating trigger foods (spicy, acidic, fatty), quitting smoking, limiting alcohol, and maintaining a healthy weight.

Infectious Esophagitis

For infectious esophagitis, specific antimicrobials are needed:

• Fluconazole (200-400mg daily for 14-21 days) for Candida, as recommended by guidelines for the treatment of candidiasis 1.
• Acyclovir (400mg five times daily for 7-14 days) for herpes.
• Ganciclovir for cytomegalovirus.

Eosinophilic Esophagitis

Corticosteroids may be prescribed for eosinophilic esophagitis, often fluticasone (440-880mcg twice daily) swallowed rather than inhaled, as supported by recent consensus guidelines 1.

Severe Cases

Severe cases may require endoscopic dilation for strictures or surgical intervention like fundoplication for persistent GERD. The treatment works by reducing acid exposure, fighting infections, or decreasing inflammation, allowing the esophageal mucosa to heal. It is crucial to follow the most recent and highest quality guidelines for the management of esophagitis, such as those from the British Society of Gastroenterology 1, to ensure the best outcomes in terms of morbidity, mortality, and quality of life.

From the FDA Drug Label

Esophageal candidiasis: The recommended dosage of fluconazole tablets for esophageal candidiasis is 200 mg on the first day, followed by 100 mg once daily. Doses up to 400 mg/day may be used, based on medical judgment of the patient’s response to therapy. Patients with esophageal candidiasis should be treated for a minimum of three weeks and for at least two weeks following resolution of symptoms Esophageal candidiasis: For the treatment of esophageal candidiasis, the recommended dosage of fluconazole tablets in children is 6 mg/kg on the first day, followed by 3 mg/kg once daily. Doses up to 12 mg/kg/day may be used, based on medical judgment of the patient’s response to therapy Patients with esophageal candidiasis should be treated for a minimum of three weeks and for at least 2 weeks following the resolution of symptoms.

The recommended treatment for esophagitis due to esophageal candidiasis is:

• Adults: 200 mg on the first day, followed by 100 mg once daily, for at least three weeks and for at least two weeks following resolution of symptoms.
• Children: 6 mg/kg on the first day, followed by 3 mg/kg once daily, for at least three weeks and for at least 2 weeks following the resolution of symptoms. 2

From the Research

Esophagitis Treatment Overview

• Esophagitis is a condition characterized by inflammation of the esophagus, often caused by excessive acid exposure.
• The primary goal of treatment is to reduce acid exposure and promote healing of the esophagus.

Medications for Esophagitis Treatment

• Proton pump inhibitors (PPIs) are the first-line treatment for esophagitis, as they effectively reduce gastric acid secretion 3, 4, 5.
• Histamine H2 receptor antagonists (H2RAs) may be used as a supplementary treatment for patients with nocturnal refluxes, but their acid inhibitory effect is limited due to tolerance development 5.
• Vonoprazan, a potassium-competitive acid blocker, has shown promising results in treating reflux esophagitis, nonerosive reflux disease, and PPI-resistant gastroesophageal reflux disease 4, 6.

Treatment Strategies

• Once-daily PPI therapy can be effective in healing severe reflux esophagitis, with morning or nighttime dosing showing similar efficacy 3.
• Twice-daily PPI dosing may be more effective in inducing remission in eosinophilic esophagitis than once-daily dosing, regardless of the total daily dose 7.
• Vonoprazan therapy has been shown to be effective for initial and maintenance therapy in reflux esophagitis, nonerosive esophagitis, and PPI-resistant gastroesophageal reflux disease, with significant improvements in symptoms and patient satisfaction 6.

Considerations for Treatment

• The choice of treatment should be individualized based on the severity of esophagitis, patient response, and potential side effects.
• Lifestyle modifications, such as dietary changes and weight loss, may also be recommended to help manage esophagitis symptoms 4.