What is the treatment for erosive gastritis?

Treatment of Erosive Gastritis

The treatment of erosive gastritis centers on proton pump inhibitor (PPI) therapy combined with mucosal protective agents, with initial management consisting of a 4-8 week trial of single-dose PPI therapy, escalating to twice-daily dosing if needed. 1

Initial Pharmacologic Management

PPI Therapy (First-Line)

• Start with single-dose PPI therapy for 4-8 weeks as the foundation of treatment 1
• If inadequate response after initial trial, escalate to twice-daily PPI dosing or switch to a more potent acid suppressive agent 2
• Optimize PPI timing: ensure proper dosing schedule (typically 30-60 minutes before meals) to maximize acid suppression 2

Mucosal Protective Agents (Adjunctive)

• Combination therapy with mucosal protective agents plus PPI is more effective than PPI alone for erosive gastritis, particularly in patients with epigastric pain 3, 4
• Rebamipide combined with nizatidine showed significantly better erosion improvement rates (62.0%) compared to nizatidine alone (49.2%) in a 2024 multicenter trial 4
• Misoprostol (200 mcg twice daily) demonstrated significant reduction in both symptom scores and endoscopic erosion scores compared to placebo in controlled trials 5

Symptom-Directed Treatment Strategy

For Epigastric Pain

• Combination of mucosal protective agent plus PPI is most effective 3
• This addresses both acid suppression and mucosal healing mechanisms

For Postprandial Fullness, Acid Regurgitation, Early Satiety, or Nausea

• Mucosal protective agents appear more promising as primary therapy 3
• Consider adding prokinetics if concomitant gastroparesis is suspected 2

For Breakthrough Symptoms

• Alginate antacids for post-prandial or nighttime breakthrough symptoms 2
• Nighttime H2-receptor antagonists (H2RAs) for nocturnal symptoms, though limited by tachyphylaxis 2

Lifestyle Modifications (Essential Concurrent Therapy)

• Avoid food intake for 2-3 hours before recumbency to reduce nocturnal acid exposure 2
• Elevate head of bed and use left lateral decubitus sleeping position to minimize reflux 2
• Weight loss in obese patients significantly reduces symptoms and acid exposure 2
• Avoid trigger foods on individual basis (alcohol, NSAIDs, specific dietary irritants) 2, 3

Long-Term Management Considerations

Duration of Therapy

• Reassess after 4-8 weeks to determine treatment response 1
• If erosive lesions persist on endoscopy, continue PPI therapy indefinitely at the lowest effective dose 2
• Patients with Los Angeles Grade B or greater erosive disease require long-term single-dose PPI therapy at minimum 2

Dose Titration

• Once symptoms are controlled, attempt to wean to lowest effective dose or switch to H2RAs/antacids for maintenance 2
• Exception: Do not wean in patients with persistent erosive esophagitis (LA Grade B or higher), Barrett's esophagus, or peptic stricture 2

Treatment Algorithm

1. Initial 4-8 weeks: Single-dose PPI + mucosal protective agent + lifestyle modifications 1, 3, 4
2. If inadequate response: Escalate to twice-daily PPI or switch to more potent agent 2, 1
3. Add symptom-directed adjunctive therapy: Alginates for breakthrough, H2RAs for nocturnal symptoms, prokinetics if gastroparesis present 2
4. Reassess at 4-8 weeks: Consider endoscopy if symptoms persist despite optimization 1
5. Long-term: Maintain lowest effective dose; do not discontinue if erosive disease persists 2

Common Pitfalls to Avoid

• Inadequate PPI dosing or duration is the most common cause of treatment failure 1
• Premature discontinuation of therapy before mucosal healing is complete leads to recurrence 3, 4
• Failure to address lifestyle factors (particularly NSAIDs, alcohol, dietary triggers) undermines pharmacologic therapy 2, 3
• Not considering H. pylori testing in refractory cases, though prevalence in erosive gastritis may be lower (approximately 30%) 5
• Using PPI monotherapy when combination with mucosal protective agents is more effective for erosive gastritis specifically 3, 4

Evidence Quality Note

The 2024 multicenter Chinese study demonstrated superior efficacy of combination therapy (rebamipide/nizatidine) over monotherapy for erosive gastritis with a 62.0% vs 49.2% improvement rate (P = 0.046) 4. This represents the most recent high-quality evidence specifically addressing erosive gastritis treatment, though the AGA guidelines provide the framework for acid suppression management 2, 1.