Treatment Plan for Erosive Gastritis
Patients with erosive gastritis require daily proton pump inhibitor (PPI) therapy for initial healing followed by continuous daily maintenance therapy indefinitely to prevent recurrence of erosive lesions. 1
Initial Treatment Regimen
Start a standard-dose PPI once daily, taken 30-60 minutes before the first meal of the day for optimal acid suppression 1
- Standard doses: omeprazole 20 mg, lansoprazole 30 mg, esomeprazole 40 mg, pantoprazole 40 mg, or rabeprazole 20 mg 2
Timing is critical: PPIs must be taken before meals to coincide with the postprandial peak in active proton pumps for maximum efficacy 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 1
Treatment duration should be 4-8 weeks for initial healing of erosive lesions 1
Maintenance Therapy (Critical)
This is where most clinicians make errors—erosive gastritis requires lifelong daily PPI therapy, not on-demand or intermittent dosing.
Continuous daily PPI therapy is mandatory indefinitely after healing to prevent recurrence 1, 2
On-demand or intermittent therapy is explicitly contraindicated for documented erosive gastritis, as recurrence rates are unacceptably high with less-than-daily dosing 1, 2
Titrate to the lowest effective dose based on symptom control, but daily dosing must be maintained 1
Do not attempt step-down therapy or de-prescribing in patients with documented erosive disease, as this leads to high recurrence rates 1
Alternative Agents (Inferior Options)
H2-receptor antagonists are significantly less effective than PPIs for both healing and maintenance—patients on H2RAs are up to twice as likely to have recurrent disease 1, 2
Mucosal protective agents (such as sucralfate or alginates) may provide additional benefit, particularly for patients with epigastric pain when combined with PPIs 3
Misoprostol has therapeutic benefits for NSAID-induced gastric erosions but is not first-line for non-NSAID erosive gastritis 4
Adjunctive Lifestyle Modifications
Avoid individual trigger foods, smoking, and excessive alcohol consumption 1, 2
Discontinue NSAIDs, aspirin, corticosteroids, and oral bisphosphonates if possible, as these are gastric mucosal irritants 5
Monitoring and Follow-Up
Routine endoscopic monitoring is NOT recommended once healing is achieved 1, 2
Document the indication for long-term PPI therapy clearly in the medical record 1
Evaluate appropriateness and dosing within 12 months after PPI initiation if the diagnosis was not endoscopically confirmed 6
Critical Pitfalls to Avoid
These are the most common errors in managing erosive gastritis:
Never use on-demand or intermittent PPI therapy for documented erosive gastritis—this approach is only appropriate for non-erosive reflux disease and leads to high recurrence rates of erosive lesions 1, 2
Do not substitute H2-receptor antagonists for maintenance therapy, as they are dramatically inferior to PPIs for preventing recurrence 1, 2
Do not prescribe twice-daily PPI dosing as initial therapy without evidence of refractory disease 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 1, 2
Do not assume gastric erosions are benign—they predispose patients to frank ulcerations and ulcer complications, particularly in NSAID users 4
Special Considerations
For NSAID-induced erosive gastritis: Continue PPI therapy as above, but strongly consider discontinuing the NSAID or switching to acetaminophen if clinically feasible 5, 4
For patients with bleeding: Erosive gastritis can cause hematemesis or melena in 23.7% of cases; these patients require the same long-term daily PPI therapy after acute management 7
Symptom profile matters for adjunctive therapy: For epigastric pain, combine PPI with mucosal protective agents; for postprandial fullness or early satiety, mucosal protective agents may be particularly beneficial 3