Initial Treatment for 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. 1
First-Line Therapy Approach
Initiate standard-dose PPI therapy (e.g., omeprazole 20 mg, lansoprazole 30 mg, or esomeprazole 20 mg) once daily, administered 30-60 minutes before breakfast for optimal acid suppression. 1
Timing is critical: PPIs must be taken before meals to coincide with the postprandial peak in active proton pumps, as they are prodrugs requiring conversion in an acidic environment and need to be present when pumps are actively secreting acid. 2, 1
Treatment duration should be 4-8 weeks for initial healing of erosive gastric lesions. 1
Avoid twice-daily dosing as initial therapy, as it is not FDA-approved for erosive gastritis, lacks strong evidence support, and unnecessarily increases costs and potential adverse effects. 2, 1
Adjunctive Therapy Considerations
Mucosal protective agents (such as sucralfate or bismuth compounds) may be added to PPI therapy, particularly in patients with prominent epigastric pain, as recent real-world data from China suggests combination therapy with MPAs and PPIs may be more effective for pain relief. 3
Implement lifestyle modifications concurrently: avoid recumbency for 2-3 hours after meals, limit dietary fat intake to less than 45 grams per day, eliminate individual trigger foods, discontinue smoking, and reduce excessive alcohol consumption. 1
Critical Distinction: Maintenance Therapy is Mandatory
After initial healing, continuous daily PPI therapy is required indefinitely to prevent recurrence of erosive disease—this is not optional. 2, 1
Daily maintenance dosing is essential: on-demand or intermittent therapy is explicitly contraindicated for documented erosive gastritis, as recurrence rates are unacceptably high (approaching 80% at one year) with less-than-daily dosing. 2, 1
Titrate to the lowest effective daily dose based on symptom control during maintenance, but daily dosing must be maintained. 2, 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 erosive disease. 2, 1
Common 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. 2, 1
Do not substitute H2-receptor antagonists for maintenance therapy, as they are significantly less effective than PPIs for preventing recurrence. 2, 1
Do not attempt de-prescribing or step-down therapy in patients with documented erosive disease, as this leads to high recurrence rates. 2, 1
Do not discontinue PPIs after healing without understanding that recurrence is highly likely and continuous therapy is the standard of care. 2, 1
Alternative Considerations: Potassium-Competitive Acid Blockers
P-CABs (such as vonoprazan) may be considered for patients who fail standard PPI therapy, as they provide more potent and prolonged acid suppression with longer half-lives (6-9 hours vs 1-2 hours for PPIs) and do not require premeal dosing. 2
P-CABs are not first-line therapy for erosive gastritis at this time, but may have utility in PPI-refractory cases pending further data. 2