What is the best tablet regimen for managing acute gastritis in a patient?

Management of Acute Gastritis with Tablets

Start with a high-potency proton pump inhibitor (PPI) such as esomeprazole 20-40 mg or rabeprazole 20 mg twice daily, taken 30-60 minutes before meals, for 4-8 weeks. 1

Initial Tablet Regimen

First-Line PPI Selection

• Esomeprazole 20-40 mg twice daily or rabeprazole 20 mg twice daily are the preferred high-potency options for acute gastritis 1
• These agents provide superior acid suppression compared to lower-potency PPIs 1
• Avoid pantoprazole when possible due to significantly lower potency (40 mg pantoprazole equals only 9 mg omeprazole equivalent) 1
• Alternative options include lansoprazole 30 mg twice daily if high-potency PPIs are unavailable 1

Critical Timing Instructions

• Take PPI 30-60 minutes before a meal to maximize effectiveness 2, 1
• This timing is essential—inadequate dosing relative to meals is a common pitfall that reduces treatment efficacy 1

Mandatory H. pylori Testing

All patients with gastritis must be tested for H. pylori infection before or during initial treatment. 1

Testing Method

• Use non-invasive tests: urea breath test or monoclonal stool antigen test 1
• Avoid serological testing as it remains positive after successful treatment and cannot confirm eradication 1

If H. pylori Positive: Eradication Therapy Required

• Switch to bismuth quadruple therapy for 14 days: PPI (twice daily) + bismuth + metronidazole + tetracycline 1
• This is the preferred first-line regimen due to increasing antibiotic resistance 1
• Higher-potency PPIs (rabeprazole or esomeprazole) improve H. pylori eradication rates 1
• Confirm eradication 4-6 weeks after completing therapy using non-serological testing 1

Adjunctive Tablet Options

For Breakthrough Symptoms

• Antacids provide rapid, temporary relief and can be used on-demand between PPI doses 1
• These do not replace PPI therapy but supplement it for immediate symptom control 1

If NSAIDs Cannot Be Discontinued

• Continue PPI therapy at full dose for gastroprotection (reduces NSAID-related ulcers by 90%) 1
• Use the lowest effective NSAID dose for the shortest duration 1
• Do not use H2-receptor antagonists (like famotidine or ranitidine) for gastroprotection—they decrease duodenal ulcer risk but not gastric ulcer risk 1

Treatment Duration and Reassessment

• Initial treatment course: 4-8 weeks 2, 1
• Reassess symptoms after this period 2
• If inadequate response, increase to twice-daily dosing or switch to a more potent PPI 2
• Once symptoms resolve, taper to the lowest effective dose 2

Critical Pitfalls to Avoid

Common Errors That Compromise Treatment

• Inadequate PPI dosing or wrong timing relative to meals—PPIs must be taken 30-60 minutes before eating 1
• Premature discontinuation of treatment before completing the 4-8 week course 1
• Failure to test for and address H. pylori infection—this leads to persistent disease and potential complications 1
• Relying on symptom resolution alone without confirming H. pylori eradication when infection was present 1
• Using buffered or coated aspirin thinking it decreases GI risk—it does not provide significant protection 1
• Combining multiple NSAIDs—this dramatically increases gastritis risk, especially with aspirin 1

Special Considerations for High-Risk Patients

NSAID-Induced Gastritis

• Discontinue NSAIDs if possible 1
• If NSAIDs must continue, add PPI therapy for gastroprotection 1
• Consider H. pylori eradication before starting long-term NSAID therapy 1
• High-risk patients (history of previous ulcer, concomitant corticosteroid use) require intensive gastroprotection with PPI therapy 1

Long-Term PPI Users

• If continuing PPI therapy beyond 12 months in unproven GERD/gastritis, consider endoscopy with prolonged reflux monitoring to establish appropriateness of long-term therapy 2
• H. pylori eradication in patients on long-term PPIs heals gastritis and prevents progression to atrophic gastritis 1