What is the recommended pharmacotherapy for esophagitis?

Pharmacotherapy for Esophagitis

For esophagitis treatment, proton pump inhibitors (PPIs) are the first-line therapy, with topical steroids recommended for eosinophilic esophagitis when PPIs are ineffective. The optimal pharmacological approach depends on the specific type of esophagitis, with different strategies for reflux-related versus eosinophilic esophagitis.

Reflux Esophagitis Treatment

First-Line Therapy

• PPI therapy is the cornerstone of treatment for reflux esophagitis 1
  • Start with once-daily standard dose (e.g., omeprazole 20 mg, esomeprazole 20-40 mg)
  • Take 30-60 minutes before breakfast for optimal effect
  • If symptoms persist after 4 weeks, increase to twice-daily dosing 1

Treatment Duration and Maintenance

• Initial treatment should continue for 8-12 weeks to achieve healing 1
• After healing, maintenance therapy is typically required as relapse rates exceed 80% within 6 months without continued treatment 2
• For maintenance:
  • Use the lowest effective dose that controls symptoms
  • Esomeprazole 20 mg daily maintains healing in over 93% of patients at 6 months 3

For Severe or Refractory Cases

• Double-dose PPI (in divided doses, before breakfast and dinner) 4
• Consider switching to another PPI if response is inadequate
• Ranitidine (H2 receptor antagonist) may be used but is significantly less effective than PPIs for severe esophagitis 5
  • For erosive esophagitis: ranitidine 150 mg 4 times daily achieves 84% healing at 12 weeks 5

Eosinophilic Esophagitis (EoE) Treatment

First-Line Options

1. PPI Therapy

   • PPIs are effective in inducing both histological and clinical remission in EoE 6
   • Dosing: twice daily for 8-12 weeks before assessing histological response 6
   • Approximately 42% of patients with esophageal eosinophilia respond to PPI therapy 6

2. Topical Steroids

   • Strong recommendation with high-quality evidence for topical steroids in EoE 6
   • More effective than PPIs, with approximately two-thirds of patients achieving histological remission 6
   • Options include:
     • Fluticasone: 440-880 μg/day for children, 880-1760 μg/day for adolescents/adults 6
     • Budesonide: available in tablet or liquid formulations specifically for esophageal delivery
   • Administration: swallow (not inhale) the medication and avoid eating/drinking for 30 minutes afterward 6

Maintenance Therapy

• Clinical and histological relapse is high after withdrawal of topical steroid treatment 6
• Maintenance treatment is strongly recommended after achieving remission 6
• PPIs can be effective in maintaining remission in patients who initially respond to them 6

Treatment Algorithm for EoE

1. Start with PPI therapy (twice daily) for 8-12 weeks
2. If inadequate response, proceed to topical steroids
3. Assess response with repeat endoscopy and biopsies
4. For responders, continue maintenance therapy
5. For non-responders, consider dietary therapy or referral to a specialist

Ineffective Treatments for EoE

• Immunomodulators (azathioprine, 6-mercaptopurine) are not recommended 6
• Anti-TNF and anti-integrin therapies are not recommended 6
• Sodium cromoglycate, montelukast, and antihistamines are not recommended 6
• Leukotriene receptor antagonists may provide symptomatic relief but do not improve histology 6

Special Considerations

Strictures and Fibrostenotic Disease

• Endoscopists often underestimate the frequency of strictures in EoE 6
• Medical treatment with topical steroids reduces stricture development 6
• For established strictures, endoscopic dilation combined with anti-inflammatory therapy provides the best outcomes 6

Refractory Disease

• Patients with refractory EoE should be jointly managed by a gastroenterologist and allergist 6
• For patients who fail standard therapies, consider:
  • Elemental diets (effective but with low compliance) 6
  • Novel biologics (dupilumab, cendakimab, benralizumab) show promise but have limited evidence 6

Common Pitfalls

• Inadequate PPI dosing or poor timing of administration
• Failure to assess histological response with follow-up endoscopy
• Discontinuing maintenance therapy prematurely
• Overlooking strictures that may require dilation
• Not considering EoE in patients with persistent symptoms despite PPI therapy

By following this evidence-based approach to pharmacotherapy for esophagitis, clinicians can optimize treatment outcomes and reduce complications such as stricture formation and perforation.