What is the recommended treatment duration with Proton Pump Inhibitors (PPIs) for a patient on Direct Oral Anticoagulants (DOACs) with grade B esophagitis?

PPI Treatment Duration for Grade B Esophagitis in Patients on DOACs

For a patient on DOACs with Los Angeles Grade B erosive esophagitis, initiate standard-dose PPI therapy (omeprazole 20 mg, lansoprazole 30 mg, or pantoprazole 40 mg once daily) for 8 weeks, followed by long-term maintenance therapy at the lowest effective dose, as Grade B esophagitis constitutes conclusive GERD requiring continuous acid suppression. 1, 2

Initial Treatment Phase

• Standard once-daily PPI dosing for 8 weeks is the recommended initial treatment duration for Grade B erosive esophagitis 2, 3
• PPIs should be taken 30-60 minutes before meals for optimal acid suppression 2
• Grade B esophagitis (Los Angeles classification) represents conclusive GERD evidence requiring definitive treatment 1
• Healing rates with standard-dose PPI therapy approach 90% at 4 weeks in patients with Grade B esophagitis 4

Rationale for 8-Week Initial Course

• Eight weeks of PPI therapy significantly reduces symptom relapse compared to 4 weeks (47.8% vs 62.5% relapse rate) in patients with Grade A or B erosive esophagitis 3
• While 4-week therapy achieves comparable initial symptom resolution rates (77.9% vs 82.1%), the extended 8-week course provides superior durability of response 3
• This duration aligns with guideline recommendations for assessment of treatment response 1

Maintenance Therapy Requirements

Patients with Grade B erosive esophagitis require continuous long-term maintenance PPI therapy rather than on-demand therapy, as this represents more severe GERD with documented mucosal injury 2, 5

Key maintenance principles:

• Patients with healed erosive esophagitis experience 80-100% recurrence rates at one year without maintenance therapy 5
• Step down to the lowest effective dose that maintains symptom control and mucosal healing 1, 2
• Grade B esophagitis constitutes a definitive indication for long-term PPI use and should generally not be considered for PPI discontinuation 2
• Periodic reassessment of the need for continued therapy is recommended, but most patients will require indefinite treatment 1, 2

Special Considerations for DOAC Use

The concurrent use of DOACs does not alter PPI treatment duration or dosing for Grade B esophagitis, but the following considerations apply:

• PPIs provide gastroprotection in patients on anticoagulation who are at increased risk for GI bleeding
• The presence of anticoagulation therapy reinforces the importance of maintaining complete mucosal healing to prevent bleeding complications
• Standard PPI dosing and duration recommendations remain unchanged regardless of DOAC use

Treatment Algorithm

1. Weeks 0-8: Standard-dose PPI once daily (e.g., omeprazole 20 mg, lansoprazole 30 mg, or pantoprazole 40 mg) taken 30-60 minutes before breakfast 2

2. Week 8 assessment: Evaluate symptom response; consider endoscopy if symptoms persist 1

3. After week 8: Transition to long-term maintenance therapy at the lowest effective dose that maintains symptom control 1, 2

4. Ongoing management: Continue indefinite maintenance therapy with periodic reassessment, as Grade B esophagitis represents conclusive GERD requiring chronic acid suppression 1, 2

Common Pitfalls to Avoid

• Do not attempt on-demand therapy in patients with documented Grade B erosive esophagitis, as this severity requires continuous daily maintenance 2, 5
• Avoid premature discontinuation after initial symptom resolution, as mucosal healing may lag behind symptom improvement and relapse rates are extremely high 5
• Do not empirically escalate to twice-daily dosing without first ensuring proper timing of once-daily dosing (before meals) and adequate treatment duration 2
• Do not use H2-receptor antagonists as maintenance therapy for healed erosive esophagitis, as they are no better than placebo for preventing relapse 5, 6