What is the treatment for a patient with esophageal erosion caused by doxycycline (antibiotic)?

Treatment of Doxycycline-Induced Esophageal Erosion

Immediately discontinue doxycycline and initiate a proton pump inhibitor (PPI) at standard dosing once daily, taken 30-60 minutes before the first meal, combined with sucralfate for mucosal protection. 1, 2

Immediate Management

Discontinue the Offending Agent

• Stop doxycycline immediately upon diagnosis of esophageal erosion. 1, 2
• Do not attempt to continue the medication with modified administration, as the caustic injury has already occurred. 2

Initiate Acid Suppression Therapy

• Start a standard-dose PPI once daily (omeprazole 20 mg, lansoprazole 30 mg, esomeprazole 40 mg, pantoprazole 40 mg, or rabeprazole 20 mg) taken 30-60 minutes before breakfast. 3, 4
• The timing is critical—PPIs must be taken before meals to coincide with the postprandial peak in active proton pumps for maximum efficacy. 4
• Continue PPI therapy for 4-8 weeks for initial healing of erosive lesions. 3, 5

Add Mucosal Protective Agent

• Initiate sucralfate in addition to PPI therapy for enhanced mucosal protection and healing. 1, 2, 6
• Sucralfate provides a physical barrier over the ulcerated mucosa and promotes healing through local effects. 1, 6

Duration and Monitoring

Expected Clinical Course

• Symptoms typically improve significantly within 2-3 days of initiating therapy, with complete resolution expected within two weeks. 2
• Feeding can usually be resumed within 2 days as symptoms improve. 1

Follow-Up Endoscopy

• Perform follow-up endoscopy at 8 weeks (or 2 months) to confirm complete healing of esophageal ulcers. 1
• This is particularly important given that doxycycline-induced esophageal injury can cause multiple longitudinal ulcers or "kissing ulcers" (specular distribution ulcers on opposing esophageal walls). 1, 2

Long-Term Management Strategy

After Healing is Confirmed

• Once endoscopic healing is documented, wean PPI to the lowest effective dose or transition to on-demand therapy, as this represents drug-induced erosive injury rather than chronic erosive esophagitis. 4
• Unlike chronic erosive esophagitis from GERD (which requires indefinite daily PPI therapy), drug-induced esophageal erosion does not require long-term maintenance once the causative agent is removed and healing is complete. 3, 7

Critical Distinction

• Drug-induced esophageal erosion is a self-limited condition that resolves with removal of the offending agent, unlike chronic erosive esophagitis from GERD. 2
• Do not continue indefinite daily PPI therapy after documented healing unless there is concurrent GERD requiring treatment. 4

Prevention of Recurrence

Patient Education for Future Medication Use

• If doxycycline or other tetracyclines must be used again in the future, instruct patients to take the medication with a full glass of water (at least 8 ounces) and remain upright for at least 1 hour after ingestion. 8
• Avoid taking doxycycline immediately before bedtime or lying down. 8
• Take doxycycline on a full stomach to minimize direct mucosal contact. 8

Risk Factors to Address

• Identify and address patient-specific risk factors including esophageal motility disorders, reduced saliva production, and mid-esophageal anatomical compression (such as from aortic arch or left atrial enlargement). 2

Common Pitfalls to Avoid

• Do not use H2-receptor antagonists instead of PPIs for initial treatment, as PPIs are dramatically superior for healing erosive esophageal lesions. 7, 5
• Do not continue doxycycline with modified administration instructions—the medication must be discontinued. 1, 2
• Do not assume this requires lifelong PPI therapy like chronic erosive esophagitis from GERD—this is a self-limited condition once the causative drug is removed. 4, 2
• Do not overlook the need for follow-up endoscopy to confirm healing, as complications including stricture formation can occur if inadequately treated. 1

Clinical Presentation Recognition

Typical Symptoms

• Abrupt-onset severe chest pain, dysphagia, and odynophagia occurring within hours of doxycycline ingestion. 1, 2
• Symptoms can occur even after a single dose if the medication is not taken properly. 1

Endoscopic Findings

• Multiple longitudinal ulcers in the mid-to-distal esophagus, mucosal erythema, erosions, and characteristic "kissing ulcers" (specular distribution on opposing walls). 1, 2
• The mid-esophagus is most commonly affected due to anatomical compression points. 2