What is the management of gastritis medicamentosa?

Management of Gastritis Medicamentosa

The most effective management of gastritis medicamentosa (drug-induced gastritis) is discontinuation of the offending medication and initiation of proton pump inhibitor therapy for 4-8 weeks. This approach directly addresses the underlying cause while providing mucosal healing.

Understanding Gastritis Medicamentosa

Gastritis medicamentosa refers to inflammation of the gastric mucosa caused by medications. Common culprits include:

• NSAIDs (non-steroidal anti-inflammatory drugs)
• Aspirin (even low-dose)
• Corticosteroids
• Certain antibiotics
• Potassium supplements
• Iron supplements
• Chemotherapeutic agents

Management Algorithm

Step 1: Identify and Discontinue the Offending Agent

• Perform thorough medication review
• Discontinue or reduce dose of the causative medication when possible
• Consider alternative medications with less gastric toxicity

Step 2: Acid Suppression Therapy

• First-line: Proton Pump Inhibitors (PPIs)

  • Omeprazole 20-40 mg once daily for 4-8 weeks 1
  • Lansoprazole 30 mg once daily for 4-8 weeks 2
  • Use the highest potency PPI available (esomeprazole or rabeprazole preferred over pantoprazole) 3

• Alternative: H2 Receptor Antagonists

  • Ranitidine 150 mg twice daily (if PPIs contraindicated) 4
  • Less effective than PPIs but may be sufficient for milder cases

Step 3: Assess for H. pylori Infection

• Test for H. pylori infection in all patients with gastritis 3
• If positive, eradicate using appropriate regimen:
  • Bismuth quadruple therapy is now preferred first-line treatment 3
  • Avoid clarithromycin-based triple therapy due to increasing resistance 3

Step 4: Mucosal Protectants (as adjunctive therapy)

• Sucralfate 1 g four times daily before meals
• Misoprostol 200 μg four times daily (particularly if NSAID continuation is necessary)

Step 5: Follow-up and Monitoring

• Reassess symptoms after 4-8 weeks of therapy
• Consider endoscopic evaluation if symptoms persist despite therapy
• For patients requiring long-term PPI therapy, monitor for potential complications:
  • Vitamin B12, magnesium, calcium, and iron deficiencies 5
  • Increased risk of C. difficile infection 2
  • Potential increased risk of fractures with long-term use 2

Special Considerations

For Patients Requiring Continuation of Offending Drug

If the causative medication cannot be discontinued (e.g., aspirin for cardiovascular protection):

• Use lowest effective dose of the offending medication
• Consider enteric-coated or buffered formulations
• Maintain continuous PPI therapy while on the medication
• Consider H2 blockers as add-on therapy for nighttime acid breakthrough

For Patients with Atrophic Changes

• If gastritis has progressed to atrophic gastritis, regular endoscopic surveillance may be needed 3
• Consider surveillance endoscopy every 3 years for patients with advanced atrophic gastritis 3

Prevention Strategies

• Use selective COX-2 inhibitors instead of traditional NSAIDs when appropriate
• Co-prescribe PPIs with high-risk medications in susceptible individuals
• Consider H. pylori eradication before initiating long-term NSAID therapy 3

Pitfalls to Avoid

1. Don't overlook the causative agent: Simply treating symptoms without removing the cause will lead to treatment failure
2. Don't continue long-term PPI therapy unnecessarily: Use the lowest effective dose for the shortest duration needed 5
3. Don't miss H. pylori infection: Always test for and treat H. pylori, as it may coexist with drug-induced gastritis 3
4. Don't ignore warning signs: Persistent symptoms, weight loss, anemia, or dysphagia require prompt endoscopic evaluation to rule out malignancy 2

By following this structured approach, most cases of gastritis medicamentosa can be effectively managed with significant improvement in morbidity and quality of life.