Management of Erosive Gastritis
Initial Treatment
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 achieve healing of erosive gastric lesions. 1
Recommended PPI Dosing Options
- Omeprazole 20 mg once daily 2
- Lansoprazole 30 mg once daily 2
- Esomeprazole 40 mg once daily 2
- Pantoprazole 40 mg once daily 2, 3
- Rabeprazole 20 mg once daily 2
Critical Timing Considerations
- PPIs must be taken 30-60 minutes before meals to coincide with postprandial peak in active proton pumps for maximum efficacy. 1, 4
- This timing is essential for optimal acid suppression in erosive gastritis. 1
What NOT to Do Initially
- Do not use twice-daily PPI dosing as initial therapy—it is not FDA-approved for erosive gastritis, lacks strong evidence support, and unnecessarily increases costs. 1
- Do not use H2-receptor antagonists (H2RAs) as first-line therapy—they are significantly less effective than PPIs for healing erosive lesions and develop tachyphylaxis within 6 weeks. 2, 4
Long-Term Maintenance Therapy
After initial healing, patients with erosive gastritis require continuous daily PPI therapy indefinitely to prevent recurrence of erosive disease. 1
Maintenance Strategy
- Daily maintenance dosing is mandatory—titrate to the lowest effective dose based on symptom control, but daily dosing must be maintained. 2, 1
- On-demand or intermittent PPI therapy is explicitly contraindicated for patients with documented erosive gastritis, as recurrence rates are unacceptably high with less-than-daily dosing. 2, 1
- This approach is analogous to management of Los Angeles grade B erosive esophagitis. 1
Why Continuous Therapy Is Essential
- PPIs are dramatically superior to H2RAs for both healing and maintenance, with patients on H2RAs being up to twice as likely to have recurrent disease. 2, 1
- Do not attempt step-down therapy or de-prescribing in patients with documented erosive disease, as this leads to high recurrence rates. 1
Adjunctive Lifestyle Modifications
Implement these concurrent measures alongside PPI therapy: 2, 1
- Avoid recumbency for 2-3 hours after meals 2, 1
- Limit dietary fat intake to less than 45 grams per day 2, 1
- Avoid individual trigger foods 2, 1
- Eliminate smoking and limit alcohol consumption 2, 1
- Treat conditions that may exacerbate gastric acid exposure (such as sleep apnea) 2, 1
Monitoring and Follow-Up
- Routine endoscopic monitoring to assess disease progression is NOT recommended once healing is achieved. 2, 1
- The likelihood of developing stricture, Barrett's metaplasia, or adenocarcinoma within 7 years in patients with healed mucosa is only 1.9%, 0.0%, and 0.1%, respectively. 2
- Clearly document the indication for long-term PPI therapy in the medical record for patients with erosive gastritis. 1
Escalation Strategy for Treatment Failures
- If symptoms persist after 4-8 weeks of once-daily therapy, escalate to twice-daily dosing before considering alternative diagnoses. 4
- For severe erosive disease, follow-up endoscopy after 8 weeks of PPI therapy is recommended to ensure healing. 4
Critical Pitfalls to Avoid
Most Common Errors in Management
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. 2, 1
Do not substitute H2-receptor antagonists for maintenance therapy—they are significantly less effective than PPIs for preventing recurrence in patients with erosive gastritis. 2, 1
Do not prescribe twice-daily PPI dosing as initial therapy—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. 2, 1
Do not use less-than-daily PPI dosing for maintenance—recurrence rates are unacceptably high with this approach in patients with a history of erosive disease. 2, 1