What is the recommended proton pump inhibitor (PPI) regimen for patients with Barrett’s esophagitis?

PPI Recommendation for Barrett's Esophagitis

All patients with Barrett's esophagus should receive long-term PPI therapy indefinitely for symptom control, with standard once-daily dosing as the initial approach, escalating to twice-daily dosing only if symptoms persist or in patients with long-segment disease. 1

Primary Indication: Symptom Control, Not Chemoprevention

• PPIs are recommended primarily for controlling gastroesophageal reflux symptoms, not as chemopreventive agents. 2
• The 2024 NICE guidelines explicitly state that high-dose PPIs showed no clinically important effect on all-cause mortality, progression to dysplasia, or cancer development in the AspECT trial. 2
• Despite lack of definitive chemoprevention evidence, the American Gastroenterological Association recommends against discontinuing PPIs in Barrett's patients, as they may reduce progression risk to esophageal adenocarcinoma. 1
• PPIs have the best clinical profile for symptomatic management compared to H2-receptor antagonists. 2

Dosing Strategy

Initial Approach

• Start with standard once-daily PPI dosing for symptom control. 2, 1
• The dose should be reviewed regularly to assess for side effects and prevent long-term complications including bone fractures, infections, and electrolyte disturbances. 2

When to Escalate to Twice-Daily Dosing

• Consider twice-daily PPI therapy for patients who don't respond clinically to once-daily therapy. 1
• Patients with long-segment Barrett's esophagus (>3 cm circumferentially) have particularly high nocturnal acid exposure and may benefit from more aggressive acid suppression. 1
• Research demonstrates that 62% of Barrett's patients have abnormal intraesophageal pH profiles despite adequate symptom control on standard-dose esomeprazole, with significant breakthrough of acid control particularly at night. 3

Specific PPI Considerations

• Esomeprazole 40 mg twice daily demonstrated superior outcomes compared to pantoprazole 40 mg twice daily, including decreased proliferative markers (Ki67, COX-2) and better esophageal acid control. 4
• High-dose lansoprazole (60 mg daily) has been shown safe and effective for up to 3 years in controlling symptoms and healing erosive esophagitis in Barrett's patients. 5

Critical Pitfalls and Caveats

Persistent Acid Exposure Despite Treatment

• Despite PPI therapy and symptom control, many Barrett's patients continue to have pathologic acid reflux, particularly at night. 1, 3
• Nocturnal intragastric pH control may be inadequate even with standard PPI dosing, correlating with nocturnal intraesophageal acid reflux. 3
• This highlights that symptom control does not guarantee adequate acid suppression.

Surveillance Still Required

• Regular endoscopic surveillance remains necessary for all Barrett's patients on PPI therapy to monitor for dysplasia development. 1
• PPI therapy does not eliminate cancer risk or obviate the need for surveillance protocols.

Long-term Safety Monitoring

• Monitor for potential long-term side effects including osteoporosis, gastrointestinal infections, and pneumonia. 2
• High-dose PPIs were not associated with increased adverse events or all-cause mortality in the AspECT trial. 2

Alternative Management Options

Antireflux Surgery

• Antireflux surgery (Nissen fundoplication) does not offer advantages over medical PPI therapy for preventing progression to dysplasia or cancer. 1
• Surgery may be considered only for patients intolerant to PPIs or with concerns about long-term medication use. 1

Aspirin/NSAIDs

• Do not offer aspirin specifically for chemoprevention in Barrett's esophagus. 2
• The AspECT trial showed insufficient evidence to recommend aspirin, and bleeding risks may outweigh potential benefits. 2, 1

Practical Algorithm

1. Diagnose Barrett's esophagus → Initiate once-daily PPI therapy
2. Assess symptom control at 4-8 weeks
   • Symptoms controlled → Continue once-daily dosing, review regularly
   • Symptoms persist → Escalate to twice-daily dosing
3. Special considerations:
   • Long-segment Barrett's (≥3 cm) → Consider twice-daily dosing from outset 1
   • Erosive esophagitis present → Ensure adequate healing with appropriate dosing 6
4. Long-term management:
   • Continue PPI therapy indefinitely 1
   • Regular surveillance endoscopy per guidelines 1
   • Periodic dose review for side effects 2
   • Attempt to wean to lowest effective dose for symptom control, but never discontinue entirely 1