What is the initial treatment for a patient with erosive esophagus?

Initial Treatment of Erosive Esophagus

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 esophageal lesions. 1, 2

First-Line Pharmacotherapy

• Initiate omeprazole 20 mg once daily or equivalent PPI (esomeprazole 40 mg, lansoprazole 30 mg) taken 30-60 minutes before breakfast for optimal acid suppression. 1, 3
• The timing is critical—PPIs must be taken before meals to coincide with the postprandial peak in active proton pumps for maximum efficacy. 3
• Treatment duration should be 4-8 weeks for initial healing, with most patients healing within this timeframe. 1, 2
• If inadequate response after 4 weeks, consider extending treatment to 8 weeks rather than immediately escalating to twice-daily dosing. 1

Avoid Common Prescribing Errors

• Do not start with twice-daily PPI dosing as initial therapy—this approach is not FDA-approved for erosive esophagitis, lacks strong evidence support, and unnecessarily increases costs and potential adverse effects. 2, 3
• Only escalate to twice-daily dosing if standard once-daily therapy fails after 8 weeks. 2
• H2-receptor antagonists are dramatically inferior to PPIs for healing erosive esophagitis and should not be used as first-line therapy. 4

Concurrent Lifestyle Modifications

• Avoid lying down for 2-3 hours after meals to reduce nocturnal acid exposure. 3
• Limit dietary fat intake to less than 45 grams per day, as fat delays gastric emptying and increases reflux. 3
• Eliminate individual trigger foods, smoking, and excessive alcohol consumption. 3
• Implement weight management strategies if overweight or obese. 2

Critical Long-Term Management Principle

Patients with documented erosive esophagitis require continuous daily PPI therapy indefinitely after healing to prevent recurrence—this is fundamentally different from non-erosive reflux disease. 2, 3

• Recurrence rates of erosive esophagitis approach 80-88% within 6 months if PPIs are discontinued after healing. 5, 4
• On-demand or intermittent PPI therapy is explicitly contraindicated for erosive esophagitis, as recurrence rates are unacceptably high with less-than-daily dosing. 2, 3
• Patients with severe erosive esophagitis (Los Angeles grade C/D), esophageal ulcers, or peptic strictures should generally not be considered for PPI discontinuation. 2

Maintenance Strategy After Healing

• Once healed, maintain with the lowest effective daily PPI dose that prevents recurrence—but daily dosing must be maintained. 2, 3
• Continuous daily PPI therapy maintains healing in over 90% of patients at 6 months. 6
• Document the indication for long-term PPI therapy clearly in the medical record, as erosive esophagitis is a definitive indication for chronic use. 2, 3

Monitoring Approach

• Perform follow-up endoscopy at 8 weeks if symptoms persist despite therapy, as persistent dysphagia may indicate failed healing. 7
• Routine endoscopic monitoring after documented healing is not recommended unless symptoms recur. 3
• Dysphagia is present in 37% of patients with erosive esophagitis at baseline and resolves with PPI therapy in 83% of cases. 7

Special Considerations for Severe Disease

• For severe erosive esophagitis (grade 4 or Los Angeles grade D), consider intravenous pantoprazole 80 mg loading dose followed by 8 mg/hour continuous infusion for 72 hours if oral therapy is not feasible or if rapid healing is required. 8
• Patients with Barrett's esophagus or history of esophageal stricture require indefinite daily PPI therapy and should never be considered for de-prescribing. 2

Key Pitfall to Avoid

Never treat erosive esophagitis the same as non-erosive reflux disease—erosive disease mandates continuous daily PPI therapy after healing, whereas non-erosive disease may be managed with on-demand therapy. 2, 3 This distinction is critical, as attempting step-down or intermittent therapy in patients with documented erosive disease leads to rapid recurrence of mucosal injury. 2, 5