Management of Erosive Esophagitis

Initial Treatment Strategy

The American Gastroenterological Association recommends that patients with erosive esophagitis require daily proton pump inhibitor (PPI) therapy for both initial healing and long-term maintenance, with PPIs being dramatically superior to H2-receptor antagonists and essential for preventing recurrence of erosive disease 1, 2
The American Academy of Pediatrics suggests starting with a standard-dose PPI once daily, such as omeprazole 20 mg, lansoprazole 30 mg, esomeprazole 40 mg, pantoprazole 40 mg, or rabeprazole 20 mg 3, 4

The American Gastroenterological Association recommends that patients with healed erosive esophagitis require continuous daily PPI therapy indefinitely 1, 2, 5
On-demand or less-than-daily PPI dosing is explicitly not recommended for patients with a history of erosive esophagitis, as recurrence rates are unacceptably high 6, 2, 5

H2-receptor antagonists (H2RAs) are significantly less effective than PPIs for both healing and maintenance of erosive esophagitis 3, 2
Patients randomized to H2RAs are up to twice as likely to have recurrent esophagitis compared to PPIs 2, 5

Routine endoscopic monitoring to assess disease progression is NOT recommended in patients with erosive or non-erosive reflux disease 2, 5
The likelihood of developing stricture, Barrett's metaplasia, or adenocarcinoma within 7 years in patients with healed mucosa is only 1.9%, 0.0%, and 0.1%, respectively 2, 5

Avoid recumbency for 2-3 hours after meals, avoid individual trigger foods, limit fat intake to less than 45 grams per day, avoid smoking and limit alcohol consumption, and treat conditions that may exacerbate reflux, such as sleep apnea 7

Do not use on-demand PPI therapy for patients with known erosive esophagitis—this leads to high recurrence rates of erosive disease 6, 2, 5
Do not substitute H2RAs for maintenance therapy in patients with healed erosive esophagitis—they are ineffective 2
Do not discontinue PPIs in patients with severe (grade C/D) erosive esophagitis without careful discussion of risks 1