What is the recommended treatment for reflux esophagitis?

Treatment of Reflux Esophagitis

Proton pump inhibitors (PPIs) are the first-line treatment for reflux esophagitis, with once-daily dosing initially, escalating to twice-daily dosing for patients with inadequate response. 1, 2

Initial Treatment Approach

First-line Therapy

• PPIs: The most effective medication class for healing erosive esophagitis
  • Standard initial dosing: Once daily, 30-60 minutes before the first meal of the day
  • Options include lansoprazole 30mg, omeprazole 20mg, esomeprazole 40mg
  • Lansoprazole 30mg daily has demonstrated healing rates of 81.3% at 4 weeks and 95.4% at 8 weeks 3
  • Esomeprazole 40mg has shown superior healing rates compared to both omeprazole 20mg and lansoprazole 30mg, particularly for severe grades of esophagitis 4

Alternative First-line Options

• H2-receptor antagonists (H2RAs): Less effective than PPIs but still superior to placebo
  • Can be used when PPIs are contraindicated or not tolerated
  • Administered 2-3 times daily due to shorter duration of action (approximately 6 hours) 1
  • Caution: Tachyphylaxis can develop within 6 weeks of initiation, limiting long-term efficacy 1

Management of Inadequate Response

For Patients with Incomplete Response to Once-Daily PPI

1. Verify proper PPI administration (30-60 minutes before meals)
2. Increase to twice-daily PPI dosing - expert opinion strongly supports this approach for improved symptom relief 1, 2
3. Consider switching to a different PPI if side effects occur (headache, diarrhea, constipation, abdominal pain) 1, 2

For Patients with Inadequate Response to Twice-Daily PPI

• Consider these patients treatment failures requiring further evaluation 1
• Recommended diagnostic workup:
  • Endoscopy with biopsy to evaluate for eosinophilic esophagitis or other conditions 1, 2
  • Manometry to evaluate esophageal motor function 1
  • Ambulatory pH or impedance-pH monitoring (after 7 days off PPI) 1, 2

Adjunctive Therapies

• For breakthrough symptoms: Antacids (most rapid onset of action) 1
• For nocturnal symptoms: Consider adding H2RA at bedtime, though evidence for improved efficacy is weak 1, 2
• For regurgitation symptoms: Consider baclofen (GABA-B receptor agonist) 2
• For coexistent gastroparesis: Consider prokinetics 2

Lifestyle Modifications

• Weight loss for overweight/obese patients 2
• Elevate head of bed 6-8 inches 2
• Avoid eating 2-3 hours before lying down 2
• Smaller, more frequent meals 2
• Limit dietary fat and avoid trigger foods 2

Maintenance Therapy

• After healing of erosive esophagitis, maintenance therapy with PPIs is often necessary to prevent relapse
• Lansoprazole 15-30mg daily has shown effective maintenance of healing (67-90% remained in remission at 12 months compared to 13-24% with placebo) 3
• Symptom severity before treatment is a significant predictor of relapse during maintenance therapy 5

Common Pitfalls

1. Inadequate PPI dosing: Ensure proper timing (before meals) and consider twice-daily dosing for inadequate response 1, 2
2. Failure to identify alternative diagnoses: Consider eosinophilic esophagitis in PPI-resistant cases 2
3. Overuse of PPIs: Particularly in infants without documented GERD 1, 2
4. Inadequate duration of therapy: Severe esophagitis may require 8 weeks or longer for complete healing 3
5. Failure to address lifestyle factors: Weight loss and dietary modifications are important adjuncts to medication 2

For patients with persistent symptoms despite optimal medical therapy and confirmed GERD on objective testing, surgical options such as laparoscopic fundoplication or endoscopic procedures may be considered 2.