What is the treatment for gastritis with Proton Pump Inhibitors (PPIs)?

Treatment of Gastritis with Proton Pump Inhibitors

For gastritis treatment, PPIs should be dosed at omeprazole 20 mg twice daily (or equivalent higher-potency PPI) for 8-12 weeks, with the specific regimen depending on whether the gastritis is H. pylori-associated or non-infectious. 1

H. pylori-Associated Gastritis

PPIs are essential components of H. pylori eradication therapy, which cures the underlying infectious gastritis. 2

First-Line Treatment Selection

The choice of regimen depends on local clarithromycin resistance rates:

• In areas with clarithromycin resistance >15-20%: Use bismuth quadruple therapy (bismuth, tetracycline, metronidazole, plus PPI twice daily) for 14 days 2
• In areas with low clarithromycin resistance (<15%): PPI-clarithromycin-amoxicillin triple therapy for 14 days is acceptable 2
• If bismuth unavailable in high-resistance areas: Sequential or concomitant therapy may be used, though these are now considered less optimal 2

PPI Dosing Specifics for H. pylori Eradication

• Minimum dose: Omeprazole 40 mg daily (or equivalent: esomeprazole 20 mg, rabeprazole 20 mg, lansoprazole 45 mg) 2
• Optimal dosing: Twice daily administration 30 minutes before meals 2
• Avoid pantoprazole: It has lower relative potency (40 mg pantoprazole = only 9 mg omeprazole equivalent) 2
• Preferred agents: Esomeprazole 20-40 mg twice daily or rabeprazole 20-40 mg twice daily for highest potency 2

Treatment Duration

• Standard duration: 14 days for all first-line regimens to maximize eradication success 2
• Extending from 7 to 10-14 days improves eradication by approximately 5% 2

After Treatment Failure

• Second-line options: Bismuth quadruple therapy or levofloxacin triple therapy (if not used first-line and local resistance is low) 2
• Third-line and beyond: Obtain antimicrobial susceptibility testing whenever possible 2
• Avoid repeating failed antibiotics: If clarithromycin, levofloxacin, or metronidazole previously failed, do not reuse them 2

Non-H. pylori Gastritis

For gastritis without H. pylori infection (including NSAID-induced, autoimmune, or idiopathic gastritis):

Standard Dosing

• Initial therapy: Omeprazole 20 mg twice daily 1
• Duration: 8-12 weeks for initial treatment 1
• Maintenance: Long-term therapy may be necessary for chronic or recurrent gastritis 1

Dose Adjustments

• Do not reduce below recommended levels, especially in primary care settings 2, 1
• For inadequate response: Consider switching to higher-potency PPIs (esomeprazole or rabeprazole) rather than increasing omeprazole dose 2, 1

Critical Clinical Considerations

Communication with Primary Care

Clearly document that PPI is prescribed for gastritis treatment, not GERD, to prevent inappropriate dose reduction in primary care 2, 1

Monitoring and Follow-Up

• For H. pylori gastritis: Confirm eradication with urea breath test or validated monoclonal stool antigen test at least 4 weeks after completing antibiotics (not serology) 2
• For chronic PPI use: Monitor for potential adverse effects including hypomagnesemia and vitamin B12 deficiency 3

Rebound Acid Hypersecretion

Warn patients that discontinuing long-term PPI therapy may cause transient upper GI symptoms due to rebound acid hypersecretion 2

H. pylori and Long-Term PPI Interaction

• PPI therapy in H. pylori-positive patients promotes corpus-predominant pangastritis and accelerates atrophic gastritis development 4, 5, 6
• This corpus gastritis develops within 1 week of starting PPI therapy 6
• H. pylori eradication fully reverses this pangastritis, even after years of PPI therapy 4
• Therefore, test and treat H. pylori in any patient requiring long-term PPI maintenance 4

Common Pitfalls to Avoid

• Do not use once-daily dosing for H. pylori eradication: Twice-daily dosing shows superior efficacy 2
• Do not use 7-day regimens: They are inferior to 14-day courses 2
• Do not ignore local antibiotic resistance patterns: Treatment selection must account for regional resistance rates 2
• Do not continue empiric triple therapy in areas with clarithromycin resistance >15-20%: This approach fails in the majority of patients 2