Treatment for Gastritis
First-line treatment for gastritis is proton pump inhibitors (PPIs) such as esomeprazole or rabeprazole at 20-40 mg twice daily, with higher potency PPIs preferred over pantoprazole. 1
Types of Gastritis and Initial Approach
Gastritis can be classified into several types, each requiring specific consideration:
- H. pylori-associated gastritis
- NSAID-induced gastritis
- Stress-related gastritis
- Alcohol-induced gastritis
- Autoimmune gastritis
- Hemorrhagic gastritis
Step 1: Diagnosis and Testing
Before initiating treatment, determine if H. pylori is present:
- Use non-invasive testing methods:
- Urea breath test
- Monoclonal stool antigen tests
- Validated serological tests 1
Step 2: Initial Treatment
For All Types of Gastritis:
- PPI therapy: Esomeprazole or rabeprazole 20-40 mg twice daily 1
For H. pylori-Positive Gastritis:
- Triple therapy is recommended:
For NSAID-Induced Gastritis:
- Discontinue NSAIDs if possible
- PPI therapy as above
For Symptomatic Relief:
- Histamine-2 (H2) receptor antagonists like ranitidine can be used as an alternative for gastritis or gastroesophageal reflux 2
- Standard dosage: 150 mg twice daily 3
Treatment Duration and Follow-up
- Reassess symptoms after 2-4 weeks of therapy 1
- Consider endoscopic evaluation if symptoms persist despite 4-8 weeks of therapy 1
- For H. pylori eradication, confirm successful treatment with follow-up testing
Special Considerations
H. pylori Eradication
Eradication therapy is the cornerstone of management for H. pylori-positive chronic gastritis 1. It:
- Prevents recurrence in patients with peptic ulcer disease (>90% cure rate)
- Provides long-term relief in approximately 1 in 12 patients with functional dyspepsia
- Is particularly beneficial before starting NSAID treatment
- Is mandatory in patients with a history of peptic ulcer 1
Caution with Long-term PPI Use
Long-term PPI use in H. pylori-positive patients can accelerate progression to atrophic gastritis 1. This is an important consideration for maintenance therapy.
Efficacy of Different PPIs
Research suggests that rabeprazole has a more rapid onset of H+,K+-ATPase inhibition than other PPIs and, compared with omeprazole, a greater effect on intragastric pH after the first dose 4. Lansoprazole has shown the most effective antibacterial activity against H. pylori, similar to omeprazole, while pantoprazole is less effective 5.
Treatment Response
Most patients with gastritis show significant improvement with appropriate therapy. Studies have shown that PPIs administered once daily produced endoscopic evidence of healing in >90% of patients with duodenal ulcer after 4 weeks of treatment, in >90% of those with gastric ulcer after 6 weeks of treatment 4.
In comparative studies, pantoprazole 40 mg once daily has shown complete ulcer healing in 88% of patients with gastric ulcers after 4 weeks, compared to 77% with omeprazole 20 mg 6.
Common Pitfalls to Avoid
Failing to test for H. pylori: Always test for H. pylori infection before initiating treatment for gastritis.
Using pantoprazole as first-line: Avoid pantoprazole when possible due to lower relative potency compared to other PPIs 1.
Inadequate treatment duration: Ensure full course of therapy, especially for H. pylori eradication (10-14 days).
Not reassessing symptoms: Always reassess symptoms after 2-4 weeks of therapy and consider endoscopic evaluation if symptoms persist despite 4-8 weeks of therapy 1.
Overlooking dietary factors: Advise patients to avoid irritants like alcohol, spicy foods, and NSAIDs during treatment.