From the Guidelines
A patient with moderate to severe gastritis despite treatment with dexlansoprazole 60mg orally once daily, who denies nonsteroidal anti-inflammatory drug (NSAID) use and reports adherence to their medication regimen, warrants further evaluation.
Potential Causes and Next Steps
The patient's lack of response to a proton pump inhibitor (PPI) at a standard dose suggests the need to assess for potential causes of refractory gastritis, such as Helicobacter pylori infection or other underlying conditions 1.
- Consideration should be given to:
- Increasing the PPI dose, as a trial of FDA-approved single-dose PPI therapy for 4-8 weeks is recommended, with assessment of response at 4-8 weeks 1
- Switching to an alternative PPI such as omeprazole or pantoprazole 1
- Adding additional therapies, such as sucralfate or misoprostol, to manage symptoms and promote healing
Diagnostic Approach
A stepwise diagnostic approach will identify mechanisms driving symptoms for a precision management approach 1.
- Patients should receive education on GERD pathophysiology and lifestyle modifications, and be involved in a shared decision-making model
- Objective reflux testing should be offered to establish a diagnosis of GERD and a long-term management plan
- Upper GI endoscopy is warranted in PPI non-response, presence of alarm signs/symptoms, isolated extra-esophageal symptoms, or in patients who meet criteria to undergo screening for Barrett’s esophagus 1
From the FDA Drug Label
5.1 Presence of Gastric Malignancy In adults, symptomatic response to therapy with dexlansoprazole does not preclude the presence of gastric malignancy. Consider additional follow-up and diagnostic testing in adult patients who have a suboptimal response or an early symptomatic relapse after completing treatment with a PPI. In older patients, also consider an endoscopy.
The patient with moderate to severe gastritis despite Dexilant (Dexlansoprazole) 60mg po qd and no NSAID use should be considered for additional follow-up and diagnostic testing to rule out gastric malignancy. An endoscopy should also be considered, especially in older patients. 2
From the Research
Considerations for Moderate to Severe Gastritis
- The patient's condition may be related to Helicobacter pylori (Hp) infection, which is a major cause of chronic gastritis and is linked to gastric atrophy and cancer 3.
- Despite the use of Dexilant (Dexlansoprazole) 60mg po qd, the patient's symptoms persist, suggesting that the treatment may not be effective in eradicating the Hp infection or reducing inflammation 3, 4.
- The patient's lack of NSAID use reduces the likelihood of NSAID-induced gastritis, but other factors such as Hp infection, autoimmune gastritis, or other forms of gastritis should be considered 5, 6.
Potential Next Steps
- Testing for Hp infection using conventional methods or immunoblotting of sera against Hp whole-cell protein lysates may be necessary to determine the presence of active or past infection 3.
- Eradication treatment for Hp infection may be necessary, with goals of curing the infection, resolving inflammation, and preventing gastric cancer 3.
- Alternative treatment regimens, such as bismuth-based therapy, may be considered, especially in cases of atrophic gastritis 3.
- A review of the patient's medication history and potential interactions with other medications may be necessary to rule out other causes of gastritis 7.