What are the treatment options for epigastritis?

Treatment Options for Epigastritis

Proton pump inhibitors (PPIs) are the first-line treatment for epigastritis, with omeprazole 20 mg twice daily being the most effective regimen for at least 8-12 weeks to achieve optimal symptom control and histological remission. 1

First-Line Treatment: Proton Pump Inhibitors

Recommended PPI Regimen

• Adults: Omeprazole 20 mg twice daily for 8-12 weeks 1
• Children: Omeprazole 1 mg/kg twice daily (up to 40 mg twice daily) for 8-12 weeks 1
• Timing: Take 30-60 minutes before meals for optimal efficacy 2

PPI Options and Standard Dosing

PPI	Standard Dose
Omeprazole	20 mg once/twice daily
Lansoprazole	30 mg once daily
Pantoprazole	40 mg once daily
Rabeprazole	20 mg once daily

Omeprazole is the only PPI that has been thoroughly assessed specifically for epigastritis treatment, showing superior efficacy when administered twice daily compared to once daily dosing 1.

Efficacy and Response Assessment

• High-dose PPI therapy (omeprazole 20 mg twice daily) shows significantly higher clinicopathological response rates (50.8%) compared to standard or low-dose regimens (35.8%) 1
• Treatment duration of 8-10 weeks shows 50.4% response rate, while 10-12 weeks shows improved response at 65.2% 1
• Repeat endoscopy with biopsies is recommended after 8-12 weeks to assess histological response 1

Maintenance Therapy

For patients who achieve histological remission with initial PPI therapy:

• Continue maintenance PPI therapy (e.g., esomeprazole 1 mg/kg/day, maximum 40 mg/day) 1
• Long-term histological remission is maintained in approximately 70% of patients on maintenance therapy 1
• Studies show sustained histological remission in 73% and clinical remission in 100% of patients on maintenance PPI therapy for at least 12 months 2

Dietary Management Options

For patients with inadequate response to PPI therapy or those preferring non-pharmacological approaches:

Step-Up Dietary Approach

1. Two-food elimination diet (milk +/- wheat or egg) for 8-12 weeks, then repeat endoscopy 1
2. If in remission, reintroduce one food at a time for 8-12 weeks with endoscopy after each reintroduction
3. If not in remission, proceed to four-food elimination diet (milk, wheat, egg, soya) for 8-12 weeks 1
4. If still not in remission, consider six-food elimination diet (milk, wheat, egg, soya, fish/shellfish, tree nuts/peanuts) 1

The six-food elimination diet shows higher histological remission rates (79%) compared to four-food (60%) and two-food (43%) elimination diets, but has lower compliance rates 1.

Elemental Diet Option

For refractory cases:

• Exclusive elemental diets using amino acid-based feeds are highly effective but have significant drawbacks 1
• Should be reserved for patients refractory to other treatments due to:
  • High withdrawal rates
  • Weight loss concerns
  • Poor compliance
  • High cost

Important Clinical Considerations

Treatment Pitfalls to Avoid

1. Inadequate PPI dosing: Using standard once-daily dosing instead of twice-daily high-dose regimen reduces efficacy 1
2. Insufficient treatment duration: Treatment less than 8 weeks may not achieve optimal response 1
3. Poor timing of PPI administration: Taking PPIs without regard to meals reduces efficacy 2
4. Abrupt discontinuation: May lead to rebound acid hypersecretion and symptom recurrence 3

Special Populations

• Hepatic impairment: Consider dose reduction for patients with severe liver disease 2
• Asian patients: May require lower maintenance doses of omeprazole (10 mg daily) 2
• Hemodialysis patients: Pantoprazole is preferred due to minimal renal elimination 2

Combination Therapy Options

• For breakthrough symptoms: Add alginate antacids 2
• For nocturnal symptoms: Consider adding H2 receptor antagonists at night 2
• For regurgitation/belching symptoms: Consider baclofen 2
• For coexistent gastroparesis: Consider prokinetics 2

By following this treatment algorithm, most patients with epigastritis will achieve significant symptom improvement and histological remission, with maintenance therapy preventing relapse in the majority of cases.