From the Guidelines
Esophagitis should be treated based on its underlying cause, with infectious esophagitis typically requiring pathogen-specific treatment, such as fluconazole 200-400mg daily for 14-21 days for candida, as recommended by available guidelines 1. When managing esophagitis, it's crucial to identify the underlying cause to provide effective treatment.
Causes of Esophagitis
- Reflux esophagitis: treated with lifestyle modifications and medication therapy, including proton pump inhibitors (PPIs) such as omeprazole or pantoprazole, and H2 blockers like famotidine 1.
- Eosinophilic esophagitis: treated with dietary elimination of trigger foods and topical steroids like fluticasone or budesonide.
- Infectious esophagitis: requires pathogen-specific treatment, with candida esophagitis being the most commonly encountered infectious esophagitis, presenting with white nummular lesions and diagnosed with cytobrush or esophageal biopsies 1.
Treatment of Infectious Esophagitis
- Candida esophagitis: treated with fluconazole 200-400mg daily for 14-21 days, as recommended by available guidelines 1.
- Herpes simplex virus (HSV) esophagitis: treated with acyclovir 400mg five times daily for 14-21 days.
- Cytomegalovirus (CMV) esophagitis: treated with ganciclovir.
Importance of Prompt Treatment
Prompt treatment of esophagitis is essential to prevent chronic inflammation, which can lead to strictures, Barrett's esophagus, or even esophageal cancer in severe cases.
Key Considerations
- Suggested risk factors for candida esophagitis include recent antibiotics, local or systemic steroids or immunosuppression, malignancy, proton pump inhibitor use, older age, chronic alcohol use, chronic kidney disease, diabetes, and motility disorders that lead to esophageal stasis 1.
- Available guidelines recommend fluconazole as the preferred treatment for candida esophagitis, with nystatin used as prophylaxis for patients at high risk or when it is unclear whether infection or colonization is present 1.
From the FDA Drug Label
1.5 Treatment of Erosive Esophagitis (EE) Due to Acid-Mediated GERD Pediatric Patients 2 Years of Age to Adults Omeprazole delayed-release capsules are indicated for the short-term treatment (4 to 8 weeks) of EE due to acid-mediated GERD that has been diagnosed by endoscopy in patients 2 years of age and older
- Esophagitis is treated with omeprazole delayed-release capsules for the short-term treatment (4 to 8 weeks) of EE due to acid-mediated GERD in patients 2 years of age and older 2
- The treatment duration for esophagitis can be extended to an additional 4 weeks if the patient does not respond to the initial 8 weeks of treatment 2
- Maintenance of healing of EE due to acid-mediated GERD is also an indication for omeprazole delayed-release capsules in patients 2 years of age and older 2
From the Research
Definition and Treatment of Esophagitis
- Esophagitis is characterized by excessive esophageal acid exposure, and treatment aims to reduce this exposure to within the normal range 3.
- The first-line drug for treating reflux esophagitis is a standard-dose proton-pump inhibitor (PPI), with response rates of 90-100% for mild cases and 80-85% for severe cases 3.
Proton Pump Inhibitors (PPIs) for Esophagitis
- Esomeprazole has demonstrated higher healing rates than omeprazole at 4 and 8 weeks 4.
- Other PPIs, such as lansoprazole, pantoprazole, and rabeprazole, have not shown higher healing rates compared to omeprazole 4.
- The choice of PPI may matter in the management of reflux esophagitis, with esomeprazole being more effective than lansoprazole or pantoprazole for maintaining remission 5.
Treatment Duration and Symptom Relapse
- Prolonging PPI therapy from 4 weeks to 8 weeks reduces symptom relapse in patients with Los Angeles grade A or B erosive esophagitis 6.
- Eight weeks of PPI therapy does not increase the rate of complete symptom resolution but reduces symptom relapse compared to 4 weeks of therapy 6.
Alternative Treatment Options
- Vonoprazan, a potassium-competitive acid blocker, has rapid and potent acid-suppressive effects and may be effective for reflux esophagitis, but clinical data are still insufficient 3.
- Modification of lifestyle with PPI therapy, switching to another PPI, or changing the administration method may be effective when standard-dose PPI is not effective 3.