What is the initial treatment for a patient with reflux oesophagitis, considering their past medical history and demographic factors?

Initial Treatment for Reflux Oesophagitis

Proton pump inhibitor (PPI) therapy at 30 mg daily (lansoprazole equivalent) for 4-8 weeks is the initial treatment of choice for reflux oesophagitis, as it provides superior healing rates and safety compared to all other options. 1, 2

First-Line Treatment Algorithm

Standard Initial Therapy

• Start with a PPI at standard dosing: lansoprazole 30 mg daily, omeprazole 20-40 mg daily, or esomeprazole 40 mg daily for 4-8 weeks 2, 3
• PPIs heal erosive oesophagitis in 81-95% of patients by 4-8 weeks, compared to only 33-53% with placebo 3
• No need to time PPI administration 30-60 minutes before meals for optimal effect, contrary to older recommendations 2

Evidence Supporting PPI Superiority

• PPIs are strongly recommended over H2-receptor antagonists based on Grade A evidence showing superior healing of esophageal mucosa and symptom control 1, 2
• Lansoprazole 30 mg daily achieved 92% healing at 8 weeks versus 70% with ranitidine 150 mg twice daily 3
• PPIs are particularly effective even in patients who failed H2-receptor antagonist therapy, with 84% healing rates 3

When Initial Therapy Fails

Escalation Strategy

• If inadequate response after 4-8 weeks on once-daily PPI, increase to twice-daily dosing of the same agent 2
• Do not switch between different PPIs expecting better results without first optimizing the dose 2
• Consider endoscopy after 4-8 weeks of twice-daily therapy if symptoms persist 2

Additional Treatment Duration

• For the 5-10% of patients who don't heal after 8 weeks, an additional 8-week course may be helpful 3
• If erosive esophagitis recurs, another 8-week course is appropriate 3

Long-Term Maintenance

Preventing Relapse

• After healing, maintenance PPI therapy is essential as nearly all patients relapse within 30 weeks without treatment 4
• Lansoprazole 15-30 mg daily maintains remission in 67-90% of patients over 12 months, compared to only 13-24% with placebo 3
• The dose that induced remission should be continued for maintenance 4
• Reducing PPI dose or switching to H2-receptor antagonists significantly increases relapse rates 4

Common Pitfalls to Avoid

What NOT to Do

• Do not add H2-receptor antagonists to twice-daily PPI therapy—there is no evidence this combination improves efficacy 2
• Do not use higher than standard doses as first-line therapy 2
• Do not recommend antireflux surgery for patients symptomatically well-controlled on medical therapy (Grade D recommendation—harms outweigh benefits) 1

Surgical Considerations

• PPI therapy should be recommended over antireflux surgery as initial therapy due to superior safety, even when both offer similar efficacy 1
• Surgery mortality estimates exceed the low risk of mortality from esophageal adenocarcinoma (less than 1 in 10,000 per patient-year) 1
• Surgery is only appropriate for patients with persistent troublesome symptoms (especially regurgitation) despite optimal PPI therapy, or those responsive but intolerant to acid suppression 1

Adjunctive Measures

Lifestyle Modifications

• While commonly recommended, data supporting specific lifestyle changes are limited 5
• Antacids provide only short-lived symptom relief and are not adequate as primary therapy 5
• Prokinetic agents like metoclopramide have not been proven effective for symptom control 5

Safety of Long-Term PPI Use

Reassurance on Chronic Therapy

• Long-term PPI use appears safe, with patient data extending up to 5 years showing no documented cases of gastric cancer or endocrine neoplasia associated with PPI treatment 4
• Hypergastrinemia may occur but does not translate to clinically significant complications in the absence of genetic predisposition 4
• Gastric mucosal atrophy is more likely from H. pylori infection than PPI therapy 4