What is the recommended treatment for erosive gastritis?

Treatment of Erosive Gastritis

Start with a standard-dose proton pump inhibitor (PPI) once daily, taken 30-60 minutes before the first meal of the day, for 4-8 weeks to heal erosive lesions, followed by continuous daily PPI therapy indefinitely to prevent recurrence. 1

Initial Treatment Protocol

• Begin with standard-dose PPI once daily: omeprazole 20 mg, lansoprazole 30 mg, esomeprazole 40 mg, pantoprazole 40 mg, or rabeprazole 20 mg 1, 2
• Timing is critical—PPIs must be taken 30-60 minutes before the first meal of the day to coincide with postprandial peak in active proton pumps for maximum efficacy 1
• Avoid twice-daily dosing as initial therapy for moderate erosive gastritis, as it is not FDA-approved for this indication and lacks strong evidence support while unnecessarily increasing costs 1
• Continue initial therapy for 4-8 weeks to achieve complete healing of erosive lesions 1

Mandatory Long-Term Maintenance Strategy

After healing, patients with erosive gastritis require continuous daily PPI therapy indefinitely—this is non-negotiable. 1

• Daily maintenance dosing is essential because recurrence rates are unacceptably high with less-than-daily dosing 1, 2
• On-demand or intermittent PPI therapy is explicitly contraindicated for documented erosive gastritis (this approach is only appropriate for non-erosive reflux disease) 1, 2
• Titrate 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—patients on H2RAs are up to twice as likely to have recurrent disease 1, 2

Adjunctive Measures

• Avoid recumbency for 2-3 hours after meals 1
• Limit dietary fat intake to less than 45 grams per day 1
• Avoid individual trigger foods, smoking, and excessive alcohol consumption 1
• Treat conditions that may exacerbate gastric acid exposure 1

When to Intensify Therapy

For severe erosive gastritis with complications, escalate to twice-daily high-potency PPI therapy (esomeprazole 40 mg or rabeprazole 40 mg twice daily) taken 30-60 minutes before meals 3

Monitoring Approach

• Routine endoscopic monitoring after healing is NOT recommended 1, 2
• Clearly document the indication for long-term PPI therapy in the medical record 1
• Treatment decisions should be guided by symptom profile—for epigastric pain, PPI plus mucosal protective agent may be more effective; for postprandial fullness or early satiety, mucosal protective agents show promise 4

Critical Pitfalls to Avoid

• Never use on-demand or intermittent PPI therapy for documented erosive gastritis—this leads to high recurrence rates of erosive lesions 1, 2
• Never substitute H2-receptor antagonists for maintenance therapy—they are significantly less effective than PPIs 1, 2
• Never attempt step-down therapy or de-prescribing in patients with documented erosive disease, as this leads to high recurrence rates 1
• Never discontinue PPIs without understanding that recurrence is highly likely and continuous therapy is the standard of care 1, 2