What are the best medications for a patient with acute gastritis, considering potential causes such as Helicobacter pylori infection or Non-Steroidal Anti-Inflammatory Drug (NSAID) use?

Best Medications for Acute Gastritis

Proton pump inhibitors (PPIs) are the first-line treatment for acute gastritis, with omeprazole 20-40 mg twice daily, esomeprazole 20-40 mg twice daily, or rabeprazole 20 mg twice daily being the most effective options for symptom relief and mucosal healing. 1

Initial Treatment Approach

Start with high-potency PPIs immediately for all patients presenting with acute gastritis symptoms. 1 The recommended regimens are:

• Omeprazole 20-40 mg twice daily 1, 2
• Esomeprazole 20-40 mg twice daily (equivalent to 32 mg omeprazole) 1
• Rabeprazole 20 mg twice daily (equivalent to 36 mg omeprazole) 1
• Lansoprazole 30 mg twice daily (equivalent to 27 mg omeprazole) 1

Avoid pantoprazole when possible due to significantly lower potency—40 mg pantoprazole equals only 9 mg omeprazole. 1

PPIs should be taken 30 minutes before meals to maximize effectiveness. 1 These agents are superior to H2-receptor antagonists for healing gastric lesions and provide better overall symptom control. 1, 3

H. pylori-Associated Gastritis

Test all patients with acute gastritis for H. pylori infection using urea breath test or monoclonal stool antigen tests. 1

If H. pylori is positive, initiate bismuth quadruple therapy for 14 days as first-line treatment due to increasing antibiotic resistance: 1

• PPI (omeprazole 20 mg or equivalent) twice daily
• Bismuth subsalicylate
• Metronidazole
• Tetracycline

Alternative first-line option when bismuth is unavailable is concomitant 4-drug therapy. 1 Triple therapy with PPI + amoxicillin 1000 mg + clarithromycin 500 mg twice daily for 10-14 days remains an option in areas with low clarithromycin resistance. 4, 2

Higher-potency PPIs (rabeprazole or esomeprazole) improve H. pylori eradication rates compared to standard omeprazole. 1

NSAID-Induced Gastritis

Discontinue all NSAIDs immediately if clinically feasible. 1 This is the single most important intervention for NSAID-induced gastritis. 5

If NSAIDs cannot be stopped:

• Continue high-dose PPI therapy indefinitely for gastroprotection 1
• Use the lowest effective NSAID dose for the shortest duration 1
• Never combine multiple NSAIDs—this dramatically increases GI risk 1
• Consider switching to a COX-2 selective inhibitor plus PPI in high-risk patients 1

PPIs reduce endoscopic NSAID-related ulcers by 90% and are superior to both H2-receptor antagonists and misoprostol for preventing NSAID-induced damage. 5, 1, 6

H2-Receptor Antagonists: Limited Role

H2-receptor antagonists (ranitidine, famotidine) are NOT recommended as first-line therapy for acute gastritis. 1 They are significantly less effective than PPIs for gastric protection and only reduce duodenal ulcer risk, not gastric ulcer risk. 5, 1, 7

Standard doses of H2-receptor antagonists reduce duodenal but not gastric ulcers; double doses are required for any gastric protection, and even then efficacy is limited primarily to H. pylori-positive patients. 5

Misoprostol: Second-Line Option

Misoprostol 600-800 mg daily reduces NSAID-associated gastric ulcers by 74% and GI complications by 40%. 1, 8 However, it causes diarrhea and abdominal pain in approximately 20% of patients, severely limiting tolerability. 1, 8

Misoprostol should be reserved for patients who cannot tolerate PPIs or in whom PPIs are contraindicated. 5 Women of childbearing potential must not be pregnant when starting misoprostol and must use effective contraception, as it causes abortion, premature labor, and birth defects. 8

Adjunctive Therapy

Antacids provide rapid, temporary symptom relief and can be used on-demand for breakthrough symptoms while PPIs take effect. 1 They may be used concomitantly with PPIs without interaction. 2

High-Risk Patients Requiring Intensive Gastroprotection

Identify patients at high risk who require the most aggressive therapy: 1

• Previous peptic ulcer or ulcer complication
• Age >65 years
• Concurrent corticosteroid use
• Concurrent anticoagulation or antiplatelet therapy
• High-dose or multiple NSAID use

For these patients, combine a COX-2 inhibitor with a PPI for maximum protection. 1 If H. pylori is present, eradication should be performed before starting long-term NSAID therapy. 1

Critical Pitfalls to Avoid

• Do not use H2-receptor antagonists as first-line therapy—they are inadequate for gastric protection 5, 1
• Do not use buffered or coated aspirin thinking it reduces GI risk—it does not 5
• Do not rely on H. pylori eradication alone in patients requiring continued NSAIDs—both PPI therapy and eradication are necessary 1
• Do not underdose PPIs—inadequate dosing is a common cause of treatment failure 1
• Do not stop PPIs prematurely in NSAID users—continue indefinitely if NSAIDs cannot be discontinued 1