What is the outpatient management of esophagitis?

From the Guidelines

Outpatient management of esophagitis primarily involves acid suppression therapy with proton pump inhibitors (PPIs) as the cornerstone of treatment, with lifestyle modifications and other adjuncts as needed to improve morbidity, mortality, and quality of life outcomes. For most patients, a standard-dose PPI such as omeprazole 20mg, esomeprazole 40mg, pantoprazole 40mg, or lansoprazole 30mg once daily before breakfast for 4-8 weeks is recommended, as supported by recent guidelines 1. In more severe cases, twice-daily dosing may be necessary. Lifestyle modifications are essential adjuncts to medical therapy and include:

• Elevating the head of the bed 6-8 inches
• Avoiding meals 2-3 hours before bedtime
• Weight loss if overweight
• Avoiding trigger foods (spicy, acidic, fatty)
• Avoiding alcohol, tobacco, and NSAIDs

For breakthrough symptoms, antacids or H2-receptor antagonists like famotidine 20mg can be used. If the esophagitis is caused by Candida infection (especially in immunocompromised patients), oral fluconazole 200mg on day 1 followed by 100mg daily for 14-21 days is appropriate, as per standard treatment protocols. For eosinophilic esophagitis, swallowed topical steroids like fluticasone (440-880mcg twice daily) or budesonide (1mg twice daily) for 8 weeks, along with dietary elimination therapy, may be effective, as recommended by recent consensus guidelines 1. Patients should be reassessed after the initial treatment period, and those with persistent symptoms may require endoscopy to evaluate healing and exclude other conditions. Acid suppression works by reducing gastric acid production, allowing the esophageal mucosa to heal from acid-related injury, while antifungals and steroids target specific inflammatory or infectious causes of esophagitis, ultimately improving patient outcomes in terms of morbidity, mortality, and quality of life.

From the FDA Drug Label

Lansoprazole delayed-release capsules are indicated for short-term treatment in adults and pediatric patients 12 to 17 years of age (up to eight weeks) and pediatric patients one to 11 years of age (up to 12 weeks) for healing and symptom relief of all grades of EE For adults who do not heal with lansoprazole delayed-release capsules for eight weeks (5 to 10%), it may be helpful to give an additional eight weeks of treatment. If there is a recurrence of erosive esophagitis an additional eight week course of lansoprazole delayed-release capsules may be considered.

Outpatient management of esophagitis with lansoprazole includes:

• Short-term treatment (up to eight weeks) for healing and symptom relief of all grades of erosive esophagitis (EE)
• An additional eight weeks of treatment may be considered for adults who do not heal with initial treatment
• Maintenance of healing of EE with lansoprazole delayed-release capsules is also indicated in adults 2 2

From the Research

Esophagitis Outpatient Management

• The management of esophagitis typically involves the use of proton pump inhibitors (PPIs) to reduce stomach acid and allow the esophagus to heal 3, 4, 5, 6, 7.
• Studies have shown that PPIs such as omeprazole, lansoprazole, and pantoprazole are effective in healing erosive esophagitis and preventing recurrence 3, 4, 6.
• The choice of PPI may matter, with some studies suggesting that esomeprazole may be more effective than other PPIs in maintaining remission and relieving symptoms 5, 7.
• Initial doses of PPIs such as omeprazole 20 mg once daily and lansoprazole 30 mg once daily have been suggested, with higher doses sometimes used for more severe cases 3, 4.
• Maintenance therapy with a PPI is often necessary to prevent recurrence of esophagitis, as H2 receptor antagonists may not be effective in preventing relapse 3.

Treatment Options

• Omeprazole, lansoprazole, and pantoprazole have been compared in several studies, with omeprazole showing superior efficacy in some cases 4.
• Esomeprazole has been shown to be more effective than other PPIs in relieving symptoms and maintaining remission in some studies 5, 7.
• Lansoprazole has been shown to be effective in healing erosive reflux esophagitis resistant to H2-receptor antagonist therapy 6.

Symptom Relief

• Esomeprazole may be more effective than other PPIs in providing rapid relief of heartburn and acid reflux symptoms 7.
• The rate of endoscopic healing of reflux esophagitis has been shown to be similar among different PPIs, with no significant differences between omeprazole, lansoprazole, pantoprazole, and esomeprazole 7.