How to manage gastritis not improving with lansoprazole (Proton Pump Inhibitor - PPI)?

Management of Gastritis Not Improving with Lansoprazole

For gastritis not responding to lansoprazole, switch to a higher potency PPI such as esomeprazole 40mg or rabeprazole 40mg twice daily, and test for Helicobacter pylori infection as the most likely cause of treatment failure. 1

Evaluation of Treatment Failure

• Consider lansoprazole's relative potency compared to other PPIs - lansoprazole 30mg is equivalent to only 27mg of omeprazole, while esomeprazole 20mg equals 32mg of omeprazole and rabeprazole 20mg equals 36mg of omeprazole 1, 2
• Ensure proper timing of PPI administration - PPIs should be taken 30 minutes before meals for optimal efficacy 1, 2
• Evaluate for Helicobacter pylori infection, which is a common cause of persistent gastritis despite PPI therapy 1

Optimization of PPI Therapy

• Switch to a higher potency PPI such as esomeprazole 20-40mg or rabeprazole 20-40mg twice daily 1
• Avoid pantoprazole as it has significantly lower potency (40mg pantoprazole = only 9mg omeprazole) 1, 2
• Consider escalating to twice daily dosing of the PPI if once daily dosing is insufficient 1
• Ensure proper timing of medication - PPI should be taken 30 minutes before morning and evening meals 1

Testing for H. pylori Infection

• If not previously tested, perform diagnostic testing for H. pylori infection 1
• Consider endoscopy with biopsy if symptoms persist despite optimized PPI therapy 1
• For patients with persistent symptoms despite twice-daily PPI therapy, ambulatory pH monitoring may be necessary to confirm GERD diagnosis or identify alternative causes 1

H. pylori Eradication Regimens

If H. pylori positive, use one of these empiric therapies:

• Bismuth quadruple therapy for 14 days: Bismuth subsalicylate (e.g., Pepto-Bismol) 2 tablets q.i.d., tetracycline 500mg q.i.d., metronidazole 500mg q.i.d., plus optimized PPI twice daily 1
• Rifabutin triple therapy for 14 days: Rifabutin 150mg b.i.d., amoxicillin 1g t.i.d., plus esomeprazole or rabeprazole 40mg b.i.d. 1
• Avoid clarithromycin triple therapy unless local susceptibility testing confirms >90% effectiveness 1

Adjunctive Therapies

• Add H2-receptor antagonists for nighttime symptoms, though be aware of tachyphylaxis with prolonged use 1
• Consider alginate antacids for breakthrough symptoms, particularly effective for post-prandial symptoms 1
• For patients with regurgitation or belching symptoms, baclofen (a GABA-B agonist) may be helpful, though side effects can limit use 1
• Prokinetics may be beneficial if gastroparesis is suspected as a contributing factor 1

Lifestyle Modifications

• Implement aggressive lifestyle modifications including weight management if applicable 1
• Avoid meals within 3 hours of bedtime 1
• Elevate the head of the bed for patients with nighttime symptoms 1

When to Consider Further Evaluation

• If symptoms persist despite optimized PPI therapy and H. pylori eradication (if applicable), endoscopy with biopsy is indicated 1
• Consider high-resolution manometry and 24-hour pH-impedance monitoring to evaluate for alternative diagnoses or mechanisms of persistent symptoms 1
• For patients with normal acid exposure on testing, consider functional dyspepsia or esophageal hypersensitivity 1

Common Pitfalls to Avoid

• Failing to verify proper PPI administration timing (30 minutes before meals) 1, 2
• Using inadequate PPI dosing or lower potency PPIs for refractory cases 1, 2
• Overlooking H. pylori infection as a cause of persistent gastritis 1, 3
• Continuing ineffective therapy without objective testing to confirm diagnosis 1
• Not considering alternative diagnoses when symptoms persist despite appropriate therapy 1