Treatment of Moderate Erosive Gastritis
Moderate erosive gastritis should be treated with standard-dose proton pump inhibitor (PPI) therapy once daily, taken 30-60 minutes before meals, for 4-8 weeks initially, followed by continuous daily maintenance therapy to prevent recurrence. 1
Initial Treatment Approach
Start with a standard-dose PPI once daily (omeprazole 20 mg, lansoprazole 30 mg, or pantoprazole 40 mg) taken 30-60 minutes before the first meal of the day for optimal acid suppression. 1, 2
The timing of PPI administration is critical—PPIs must be taken before meals (not at bedtime) to coincide with postprandial peak in active proton pumps for maximum efficacy. 3, 1
Avoid twice-daily dosing as initial therapy, as it is not FDA-approved for erosive gastritis and lacks strong evidence support while increasing costs unnecessarily. 1
Treatment duration should be 4-8 weeks for initial healing of erosive lesions. 1
Maintenance Therapy Strategy
Patients with healed erosive gastritis require continuous daily PPI therapy indefinitely to prevent recurrence of erosive disease. 2
Daily maintenance dosing is essential—on-demand or intermittent therapy is explicitly contraindicated for patients with documented erosive gastritis, as recurrence rates are unacceptably high with less-than-daily dosing. 1, 2
Maintenance therapy should be titrated to the lowest effective dose based on symptom control, but daily dosing must be maintained. 1
PPIs are dramatically superior to H2-receptor antagonists for both healing and maintenance, with patients on H2RAs being up to twice as likely to have recurrent disease. 2
Adjunctive Mucosal Protective Agents
For patients with persistent epigastric pain despite PPI therapy, consider adding a mucosal protective agent (MPA) to the PPI regimen, as this combination appears more effective for pain control. 4
- MPAs may be particularly beneficial for patients with postprandial fullness, acid regurgitation, early satiety, or nausea as predominant symptoms. 4
Disease Severity Considerations
While the provided evidence focuses primarily on erosive esophagitis rather than gastritis specifically, the principles of acid suppression therapy apply similarly:
Moderate erosive gastritis (analogous to Los Angeles grade B erosive esophagitis) requires continuous daily PPI therapy after initial healing. 1, 2
Do not attempt step-down therapy or de-prescribing in patients with documented erosive disease, as this leads to high recurrence rates. 3, 1
Lifestyle Modifications
Implement concurrent lifestyle modifications including:
- Avoiding recumbency for 2-3 hours after meals
- Limiting dietary fat intake to less than 45 grams per day
- Avoiding individual trigger foods, smoking, and excessive alcohol consumption
- Treating conditions that may exacerbate gastric acid exposure 2
Monitoring and Follow-Up
Routine endoscopic monitoring to assess disease progression is not recommended once healing is achieved. 2
The indication for long-term PPI therapy should be clearly documented in the medical record. 1
Symptoms should be reassessed after 4 weeks of treatment to evaluate therapeutic response. 4
Critical Pitfalls to Avoid
Never use on-demand or intermittent PPI therapy for patients with documented erosive gastritis—this approach is only appropriate for non-erosive reflux disease and leads to high recurrence rates of erosive lesions. 1, 2
Do not substitute H2-receptor antagonists for maintenance therapy, as they are significantly less effective than PPIs for preventing recurrence. 2
Do not prescribe twice-daily PPI dosing as initial therapy, as it lacks FDA approval and proven benefit for erosive gastritis while increasing costs. 1
Do not discontinue PPIs in patients with healed erosive gastritis without understanding that recurrence is highly likely and continuous therapy is the standard of care. 3, 2