What is the best approach for managing erosive esophagitis?

Management of Erosive Esophagitis

Patients with erosive esophagitis require daily proton pump inhibitor (PPI) therapy for both initial healing and long-term maintenance, with PPIs being dramatically superior to H2-receptor antagonists and essential for preventing recurrence of erosive disease. 1

Initial Treatment Strategy

First-Line Therapy

• Start with a standard-dose PPI once daily: omeprazole 20 mg, lansoprazole 30 mg, esomeprazole 40 mg, pantoprazole 40 mg, or rabeprazole 20 mg 1
• For severe erosive esophagitis (Los Angeles Classification grade C/D), consider esomeprazole 40 mg, which demonstrates significantly higher healing rates compared to other PPIs 2
• Treatment duration should be 8 weeks for initial healing, with most patients achieving complete mucosal healing within this timeframe 3

Healing Rates

• PPIs heal erosive esophagitis in 82-93% of patients at 8 weeks, compared to only 52-70% with H2-receptor antagonists 3, 4
• Esomeprazole 40 mg provides healing rates of approximately 93% at 8 weeks for severe erosive esophagitis 2
• Lansoprazole 30 mg heals 92-100% of erosive esophagitis cases in pediatric patients by 8-12 weeks 3

Long-Term Maintenance Therapy

Mandatory Continuous PPI Therapy

• Patients with healed erosive esophagitis require continuous daily PPI therapy indefinitely 1
• Without maintenance therapy, approximately 80% of patients experience recurrence of erosive esophagitis within one year 4, 5
• On-demand or less-than-daily PPI dosing is explicitly not recommended for patients with a history of erosive esophagitis, as recurrence rates are unacceptably high 1

Maintenance Dosing

• Standard maintenance doses: lansoprazole 15-30 mg daily, esomeprazole 20 mg daily, or omeprazole 20 mg daily 1, 5, 6
• Lansoprazole 15 mg and 30 mg maintain remission in 67-90% of patients at 12 months 5
• Esomeprazole 20 mg maintains healing in over 90% of patients at 6 months and provides superior endoscopic/symptomatic remission (84.8%) compared to lansoprazole 15 mg (75.9%) 6, 7

Dose Titration

• After achieving adequate symptom control, titrate PPI to the lowest effective dose that maintains both mucosal healing and symptom control 1
• Re-evaluate treatment appropriateness and dosing within 12 months after initiation 1
• The decision regarding maintenance dose is driven by impact on quality of life rather than disease control measures 8

Special Populations Requiring Indefinite PPI Therapy

Patients Who Should NOT Discontinue PPIs

• Los Angeles Classification grade C/D erosive esophagitis: These patients should generally not be considered for PPI discontinuation unless benefits and harms are carefully weighed and discussed 1
• GERD-related complications: Patients with history of GI bleeding, stricture formation, or Barrett's esophagus require continuous PPI therapy 1
• The likelihood of developing Barrett's esophagus with healing of Los Angeles C or D esophagitis is approximately 6% 1

Alternative Therapies and Their Limitations

H2-Receptor Antagonists

• H2RAs (ranitidine, famotidine, cimetidine) are significantly less effective than PPIs for both healing and maintenance of erosive esophagitis 1, 4
• Patients randomized to H2RAs are up to twice as likely to have recurrent esophagitis compared to PPIs 1
• H2RAs develop tachyphylaxis within 6 weeks, limiting long-term effectiveness 1
• H2RAs appear no better than placebo for maintenance of healed erosive esophagitis 4

Potassium-Competitive Acid Blockers (P-CABs)

• P-CABs (vonoprazan, tegoprazan) should generally not be used as first-line therapy for milder erosive esophagitis (LA grade A/B) 1
• For LA grade A/B erosive esophagitis, P-CABs show similar healing rates to PPIs (92-99% vs 96-100% at 8 weeks) 1
• P-CABs may be considered in selected patients with documented acid-related reflux who fail twice-daily PPI therapy 1
• Maintenance data show vonoprazan 10-20 mg maintains healing in 81-99% of patients at 24 weeks 1

Monitoring and Follow-Up

Endoscopic Surveillance

• Routine endoscopic monitoring to assess disease progression is NOT recommended in patients with erosive or non-erosive reflux disease 1
• The likelihood of developing stricture, Barrett's metaplasia, or adenocarcinoma within 7 years in patients with healed mucosa is only 1.9%, 0.0%, and 0.1%, respectively 1
• Endoscopic monitoring has not been shown to diminish cancer risk 1

When to Perform Endoscopy

• Perform endoscopy if troublesome symptoms do not respond adequately to PPI trial or if alarm symptoms exist 1
• Complete endoscopic evaluation should include grading of erosive esophagitis (Los Angeles classification), assessment of hiatus hernia, and inspection for Barrett's esophagus (Prague classification with biopsy when present) 1

Adjunctive Lifestyle Modifications

• Avoid recumbency for 2-3 hours after meals 8
• Avoid individual trigger foods (coffee, chocolate, alcohol, spicy foods) 8
• Limit fat intake to less than 45 grams per day 8
• Avoid smoking and limit alcohol consumption 8
• Treat conditions that may exacerbate reflux, such as sleep apnea 8

Key Clinical Pitfalls to Avoid

Common Errors

• Do not use on-demand PPI therapy for patients with known erosive esophagitis—this leads to high recurrence rates of erosive disease 1
• Do not substitute H2RAs for maintenance therapy in patients with healed erosive esophagitis—they are ineffective 1, 4
• Do not discontinue PPIs in patients with severe (grade C/D) erosive esophagitis without careful discussion of risks 1

Risks of PPI Discontinuation

• The primary risk of reducing or discontinuing PPI therapy is increased symptom burden and recurrence of erosive disease 1, 8
• Beyond symptom recurrence, the risks associated with therapy cessation, including potential development of Barrett's esophagus, appear minimal 1, 8
• There is no high-quality evidence that continuous antisecretory therapy alters the natural history of reflux disease beyond reducing the already low incidence of peptic stricture 1, 8

Pediatric Considerations

Dosing for Children

• Ages 1-11 years: Lansoprazole 15 mg daily if ≤30 kg or 30 mg daily if >30 kg, with healing rates of 100% at 12 weeks 3
• Ages 12-17 years: Lansoprazole 30 mg daily for erosive esophagitis, with 95.5% healing rate at 8 weeks 3
• PPIs are superior to H2RAs for healing erosive esophagitis in children, though H2RAs (cimetidine, nizatidine) have shown efficacy in randomized trials 1