What is the treatment for erosive gastritis?

Treatment of Erosive Gastritis

Start with a standard-dose proton pump inhibitor (PPI) once daily, taken 30-60 minutes before the first meal, for 4-8 weeks to heal erosive lesions, followed by continuous daily PPI therapy indefinitely to prevent recurrence. 1

Initial Treatment Protocol

First-Line Pharmacotherapy

• Prescribe a standard-dose PPI once daily: omeprazole 20 mg, lansoprazole 30 mg, esomeprazole 40 mg, pantoprazole 40 mg, or rabeprazole 20 mg 1, 2
• Critical timing requirement: Administer 30-60 minutes before the first meal of the day to coincide with postprandial peak in active proton pumps for maximum acid suppression 1
• Treatment duration: Continue for 4-8 weeks for initial healing of erosive lesions 1
• Avoid twice-daily dosing as initial therapy—it lacks FDA approval for erosive gastritis, has no proven additional benefit, and unnecessarily increases costs 1

Identify and Eliminate Causative Factors

• Discontinue gastric mucosal irritants immediately: NSAIDs, aspirin, corticosteroids, and oral bisphosphonates 1
• For NSAID-induced erosive gastritis: Continue PPI therapy while discontinuing the NSAID or switching to acetaminophen 1
• Address other etiological factors: Alcohol consumption, dietary errors, and drugs like Rauwolfia derivatives or broad-spectrum antibiotics 3

Long-Term Maintenance Strategy

Mandatory Continuous Therapy

• Require continuous daily PPI therapy indefinitely after initial healing to prevent recurrence of erosive disease 1, 2
• Daily maintenance dosing is essential—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

Why H2-Receptor Antagonists Are Inadequate

• PPIs are dramatically superior to H2-receptor antagonists for both healing and maintenance therapy 1, 2
• Patients on H2RAs are up to twice as likely to have recurrent erosive disease compared to those on PPIs 1, 2
• Never substitute H2RAs for maintenance therapy in patients with healed erosive gastritis 1, 2

Adjunctive Mucosal Protective Agents

Symptom-Based Combination Therapy

• For patients with epigastric pain: Combination of a mucosal protective agent (MPA) plus PPI is more effective than PPI alone 4
• For postprandial fullness, acid regurgitation, early satiety, or nausea: Adding an MPA appears more promising 4
• Historical evidence supports MPAs: Gastro-protective drugs including almagel, deglycyrrhized licorice preparations, and vitamin A eliminated erosive alterations in 75% of patients after 3 weeks 3

Lifestyle Modifications

Concurrent Non-Pharmacologic Interventions

• Avoid recumbency for 2-3 hours after meals to reduce gastric acid exposure 1, 2
• Limit dietary fat intake to less than 45 grams per day 1, 2
• Avoid individual trigger foods, smoking, and excessive alcohol consumption 1, 2
• Treat conditions that may exacerbate gastric acid exposure 1

Monitoring and Follow-Up

Appropriate Surveillance Strategy

• 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
• Consider repeat endoscopy only if symptoms recur or fail to improve after initial treatment course

Critical Pitfalls to Avoid

Common Prescribing Errors

• 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 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 prescribe twice-daily PPI dosing as initial therapy—it lacks FDA approval and proven benefit while increasing costs 1
• Do not substitute H2-receptor antagonists for maintenance therapy—they are significantly less effective than PPIs for preventing recurrence 1, 2

Special Considerations for Refractory Cases

• For patients failing conventional therapy: Historical case series suggest short-term oral prednisolone may be beneficial, with symptomatic improvement within one week and endoscopic healing within two weeks 5
• This corticosteroid approach should be reserved for patients who fail to respond to adequate PPI therapy and elimination of causative factors 5