Treatment of Erosive Esophagitis
Patients with erosive esophagitis require daily proton pump inhibitor (PPI) therapy for both initial healing and indefinite long-term maintenance—this is non-negotiable for preventing recurrence of erosive disease. 1
Initial Treatment Approach
Start with a standard-dose PPI once daily for 4-8 weeks:
- Omeprazole 20 mg once daily 2
- Lansoprazole 30 mg once daily 3
- Esomeprazole 40 mg once daily 4
- Pantoprazole 40 mg once daily 1
- Rabeprazole 20 mg once daily 1
Among these options, esomeprazole 40 mg demonstrates superior healing rates at both 4 weeks and 8 weeks compared to omeprazole 20 mg and lansoprazole 30 mg, with significantly better heartburn relief 4. Specifically, esomeprazole 40 mg achieved healing rates of 83.3% at 4 weeks and 90% at 8 weeks 5.
For patients who fail to heal after 8 weeks, extend treatment for an additional 4-8 weeks 3, 2. Most patients heal within 4-8 weeks, but approximately 5-10% may require extended therapy 3.
Long-Term Maintenance Strategy
Once erosive esophagitis is healed, continuous daily PPI therapy must be continued indefinitely 6, 1. This is critical because:
- Patients not maintained on continuous acid suppression have extremely high recurrence rates of erosive disease 6
- Lansoprazole 15 mg or 30 mg once daily maintains remission in 79-90% of patients at 12 months 3, 7
- The likelihood of spontaneous long-term remission without maintenance therapy is negligible 6
Titrate maintenance therapy down to the lowest effective dose based on symptom control, but never discontinue entirely in patients with documented erosive esophagitis 6.
Critical Treatment Pitfalls to Avoid
Never use on-demand or less-than-daily PPI dosing for patients with a history of erosive esophagitis—this approach leads to unacceptably high recurrence rates of erosive disease and is explicitly contraindicated 6, 1. On-demand therapy may be acceptable for non-erosive GERD, but not for erosive esophagitis 6.
Do not substitute H2-receptor antagonists (H2RAs) for PPI therapy in erosive esophagitis 1. H2RAs are dramatically inferior to PPIs, with patients randomized to H2RAs being up to twice as likely to experience recurrent esophagitis 6, 1. H2RAs also develop tachyphylaxis within 6 weeks, further limiting their utility 6.
Special Populations
For pediatric patients (1-17 years):
- Ages 12-17 years: Treat for up to 8 weeks 3
- Ages 1-11 years: Treat for up to 12 weeks 3
- Dosing: 1 mg/kg per dose twice daily (maximum adult dose) 6
For therapy-resistant erosive esophagitis (failed H2RA therapy for ≥12 weeks):
- Lansoprazole 30 mg achieves 82% healing at 4 weeks and 92% at 8 weeks 8
- Both 30 mg and 60 mg doses are equally effective 8
Monitoring and Follow-Up
Routine endoscopic monitoring is NOT recommended in patients with healed erosive esophagitis 6, 1. The risk of progression to Barrett's esophagus or adenocarcinoma within 7 years is extremely low (0.0% and 0.1%, respectively) 1.
Persistent dysphagia after 4 weeks of PPI therapy may indicate failed healing 9. While dysphagia is common in erosive esophagitis (37% of patients), it resolves in 83% of patients with successful PPI treatment 9. Persistent dysphagia warrants repeat endoscopy to assess healing 9.
Adjunctive Lifestyle Modifications
While PPIs are the cornerstone of therapy, recommend:
- Avoid recumbency for 2-3 hours after meals 1
- Limit dietary fat to <45 grams per day 1
- Avoid smoking and limit alcohol consumption 1
- Treat comorbid conditions such as sleep apnea 1
Key Clinical Pearls
The decision to continue maintenance PPI therapy is driven by preventing erosive disease recurrence, not just symptom control 6. Unlike non-erosive GERD where symptom relief is the primary goal, erosive esophagitis requires continuous mucosal protection 6.
Esomeprazole 40 mg, pantoprazole 40 mg, and lansoprazole 30 mg demonstrate the best balance of effectiveness and acceptability 4. Dexlansoprazole 60 mg has significantly higher discontinuation rates due to adverse effects 4.