What is the initial treatment for esophagitis?

Initial Treatment for Esophagitis

The initial treatment for esophagitis should be proton pump inhibitors (PPIs) administered twice daily for 8-12 weeks, with omeprazole 20mg twice daily being the recommended first-line therapy. 1, 2

Types of Esophagitis and First-Line Treatment

Erosive Esophagitis

• Initial therapy: PPI twice daily for 4-8 weeks 2, 3
  • Omeprazole 20mg twice daily 2, 3
  • Esomeprazole 40mg once daily as an alternative 4
• Duration: 4-8 weeks initially, with assessment of response 3
• Efficacy: PPIs heal erosive esophagitis in 80-90% of cases 4
• Symptom resolution: Dysphagia resolves in approximately 83% of patients after 4 weeks of PPI treatment 4

Eosinophilic Esophagitis (EoE)

• Initial therapy: PPI twice daily for 8-12 weeks 2, 1
  • Omeprazole 20mg twice daily 2
  • For children: 1mg/kg per dose, twice daily (maximum adult dose) 1
• Response rate: Approximately 41.7% of EoE patients respond to PPI therapy 1
• Assessment: Endoscopy with biopsy while on treatment is required to evaluate response 1
• Remission definition: <15 eosinophils/0.3 mm² on histology 1

Treatment Algorithm

1. Start with PPI therapy:

   • Adults: Omeprazole 20mg twice daily for 8-12 weeks 2, 1
   • Children: Omeprazole 1mg/kg twice daily (maximum adult dose) 1

2. Assess response after 4-8 weeks:

   • For erosive esophagitis: Clinical improvement should be evident within 4 weeks 4
   • For eosinophilic esophagitis: Endoscopy with biopsy is required to assess histological response after 8-12 weeks 2, 1

3. If inadequate response to standard-dose PPI:

   • Increase to double-dose PPI (divided doses) 5
   • Consider switching to another PPI 5
   • Ensure proper administration timing (before meals) 5

4. For refractory eosinophilic esophagitis:

   • Consider topical swallowed corticosteroids (fluticasone or budesonide) 1, 6
   • Consider dietary therapy as an alternative approach 1, 6
     • Six-food elimination diet (79% remission rate)
     • Four-food elimination diet (60% remission rate)
     • Two-food elimination diet (43% remission rate)

Important Considerations

• Medication timing: PPIs should be taken 30-60 minutes before meals for optimal efficacy 2
• Maintenance therapy: Long-term use of PPIs is recommended for patients with esophagitis once proven clinically effective 2
• Dose titration: Maintenance therapy should be titrated to the lowest effective dose based on symptom control 2
• Continuous vs. on-demand: Continuous therapy is recommended for patients with a history of erosive esophagitis; on-demand therapy is not recommended 2

Common Pitfalls and Caveats

• Persistent dysphagia: If dysphagia persists after 4 weeks of PPI therapy, it may indicate failed healing and warrants further investigation 4
• Relapse rates: Erosive esophagitis has a high relapse rate (up to 82% within 6 months) when treatment is stopped 7
• Severity assessment: The severity of dysphagia is not a reliable predictor of the severity of erosive esophagitis 4
• PPI-responsive EoE: Approximately 23% of patients initially diagnosed with EoE will respond to PPI therapy and should be reclassified as PPI-responsive esophageal eosinophilia 6
• Endoscopic follow-up: For eosinophilic esophagitis, endoscopy with biopsy is necessary to confirm histological response, as symptoms may not correlate with histological activity 1

By following this treatment approach, most patients with esophagitis will experience significant improvement in both symptoms and mucosal healing, leading to improved quality of life and reduced risk of complications.