What is the first line treatment for gastritis?

First-Line Treatment for Gastritis

Proton pump inhibitors (PPIs) are the first-line treatment for gastritis, with bismuth quadruple therapy recommended for H. pylori-associated gastritis. 1

Treatment Algorithm for Gastritis

Step 1: Determine if H. pylori testing is indicated

• Test for H. pylori in patients with:
  • Symptoms lasting longer than 4 weeks
  • No alarm symptoms (bleeding, weight loss, dysphagia)
  • History of peptic ulcer disease

Step 2: Treatment based on H. pylori status

For H. pylori-positive gastritis:

1. First-line therapy: Bismuth quadruple therapy (14 days) 1

   • PPI (high-dose, twice daily)
   • Bismuth
   • Tetracycline
   • Metronidazole

2. Alternative if bismuth unavailable: Concomitant therapy (14 days) 1

   • PPI (high-dose, twice daily)
   • Clarithromycin 500 mg twice daily
   • Amoxicillin 1 g twice daily
   • Metronidazole 500 mg twice daily

3. PPI recommendations:

   • Use high-potency PPIs (40 mg omeprazole equivalent) twice daily 1
   • Preferred options: esomeprazole or rabeprazole 20-40 mg twice daily
   • Avoid pantoprazole (less effective for H. pylori eradication)

For H. pylori-negative gastritis:

1. First-line therapy: Full-dose PPI 1

   • Omeprazole 20 mg once daily or equivalent
   • Duration: 4-8 weeks

2. For dysmotility-like symptoms:

   • Consider adding a prokinetic agent 1

Important Clinical Considerations

PPI Selection

• Rabeprazole has a more rapid onset of action than other PPIs 2
• Esomeprazole and rabeprazole have higher relative potency 1
• PPIs differ in their potential for drug interactions (omeprazole and lansoprazole have greater potential) 2

Duration of Therapy

• For H. pylori eradication: 14 days of therapy is recommended 1
• For non-H. pylori gastritis: 4-8 weeks of PPI therapy, then trial of withdrawal 1

Common Pitfalls to Avoid

1. Inadequate PPI dosing for H. pylori eradication

   • Use high-dose PPI (at least 40 mg omeprazole equivalent twice daily) 1
   • Underdosing reduces eradication rates

2. Failing to test for H. pylori

   • H. pylori is responsible for many peptic ulcers and >80% of gastric cancer cases 1
   • Testing and treating H. pylori is cost-effective and safe in appropriate patients 1

3. Continuing long-term PPI without H. pylori eradication

   • Long-term PPI use in H. pylori-positive patients can accelerate progression to atrophic gastritis 1
   • Eradication of H. pylori in patients on long-term PPIs prevents progression to atrophic gastritis 1

4. Using clarithromycin-based triple therapy in areas with high resistance

   • Clarithromycin resistance has increased significantly 1
   • Bismuth quadruple therapy is now preferred first-line treatment 1

By following this algorithm and avoiding common pitfalls, clinicians can effectively treat gastritis and reduce the risk of complications such as peptic ulcer disease and gastric cancer.