What is the recommended treatment for gastritis?

Treatment of Gastritis

The recommended first-line treatment for gastritis is H. pylori eradication therapy for patients with confirmed H. pylori infection, and proton pump inhibitor (PPI) therapy for non-H. pylori gastritis. 1

Diagnostic Approach

• Patients >45 years with severe symptoms or any patients with alarm symptoms (anemia, weight loss, dysphagia, palpable mass, malabsorption) should be referred for endoscopy before treatment 1
• Younger patients (<45 years) without alarm symptoms can be managed in primary care with H. pylori testing and eradication 1

Treatment Algorithm

For H. pylori-Associated Gastritis:

1. First-line regimen (standard triple therapy):

   • PPI (e.g., omeprazole 20mg) twice daily
   • Amoxicillin 1g twice daily
   • Clarithromycin 500mg twice daily
   • Duration: 14 days (superior to 7-day regimens by ~5%) 1

2. For penicillin allergy (bismuth quadruple therapy):

   • PPI twice daily
   • Bismuth 300mg four times daily
   • Tetracycline 500mg four times daily
   • Metronidazole 500mg three times daily
   • Duration: 14 days 1

3. If first-line treatment fails:

   • Consider levofloxacin-based regimen:
     • PPI twice daily
     • Bismuth 300mg four times daily
     • Levofloxacin 500mg once daily
     • Tetracycline 500mg four times daily
     • Duration: 14 days 1

For Non-H. pylori Gastritis:

1. PPI therapy:
   • For gastric ulcers: PPI for 4-8 weeks 1, 2
   • For duodenal ulcers: PPI for 4 weeks 1, 2
   • For NSAID-associated gastritis: PPI therapy (superior to ranitidine and misoprostol) 1, 3

Follow-up and Confirmation of Eradication

• Confirm H. pylori eradication at least 4 weeks after completion of treatment 1
• Use urea breath test (UBT) or laboratory-based validated monoclonal stool antigen test 1
• Ensure patient has been off PPI for at least 2 weeks before testing 1

Maintenance Therapy

• For uncomplicated duodenal ulcer: No prolonged PPI therapy needed after successful H. pylori eradication 1
• For complicated duodenal ulcer: Continue PPI until H. pylori eradication is confirmed 1
• For erosive esophagitis: Long-term PPI maintenance therapy may be indicated 1, 2

Important Clinical Considerations

PPI Dosing

• High-dose PPI increases the efficacy of triple therapy by 6-10% compared to standard doses 1
• Standard PPI doses:
  • Omeprazole 20mg
  • Lansoprazole 30mg
  • Pantoprazole 40mg
  • Esomeprazole 20mg
  • Rabeprazole 20mg
  • Dexlansoprazole 30mg 1

Regional Considerations

• In areas with high clarithromycin resistance (>15-20%), avoid clarithromycin-based regimens 1

Special Populations

• For patients with renal impairment:
  • GFR 10-30 mL/min: Adjust amoxicillin to 500mg or 250mg every 12 hours
  • GFR <10 mL/min: Adjust to 500mg or 250mg every 24 hours 1
• For patients with bleeding ulcers: Start treatment when oral feeding is resumed 1

Patient Education

• Inform patients about potential side effects:
  • Darkening of stool (from bismuth)
  • Metallic taste
  • Nausea and diarrhea
  • Skin rash
  • Muscle and joint pains 1
• Emphasize the importance of completing the full course of treatment 1
• Taking medications with meals improves tolerance and efficacy 1

Pitfalls to Avoid

1. Not confirming H. pylori eradication: Always confirm eradication at least 4 weeks after treatment completion 1
2. Inadequate treatment duration: 14-day regimens are superior to 7-day regimens 1
3. Not adjusting therapy for antibiotic resistance: In areas with high clarithromycin resistance, avoid clarithromycin-based regimens 1
4. Premature PPI discontinuation: Continue PPI until complete healing for gastric ulcers 1
5. Testing for H. pylori eradication while on PPI: Ensure patient has been off PPI for at least 2 weeks before testing 1