Esophagitis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

The mainstay of therapy for reflux esophagitis is acid suppression therapy. Patients with infectious esophagitis are treated with antimicrobial therapy, whereas patients with eosinophilic esophagitis are treated with corticosteroids. Supportive therapy for esophagitis includes proton pump inhibitors, topical pain medications (gargled or swallowed), smoking and alcohol cessation, and endoscopy to remove any lodged pill fragments.

Medical Therapy

Treatment of esophagitis depends on the underlying cause:

• Reflux esophagitis: Acid suppression using proton-pump inhibitors

Lifestyle Modifications

• The following measures are recommended as the first line to treat GERD:
  • Weight loss
  • Elevating head of the bed
  • No eating two hours before going sleep
• Avoidance of the following foods and lifestyles is recommended in treatment of GERD:
  • Coffee
  • Alcohol
  • Excessive amounts of Vitamin C supplements
  • Foods high in fats
  • Smoking
  • Eating shortly before bedtime
  • Large meals
  • Chocolate and peppermint.
  • Acidic foods, such as oranges and tomatoes.
  • Cruciferous vegetables such as: Onions, cabbage, cauliflower, broccoli, spinach, brussel sprouts
  • Milk and milk-based products

Medical therapy

• The medical therapy is indicated for the patients who have persistent GERD regardless the lifystyle and food modifications.
• The following medical therapies are strongly recommended by the American College of Gastroenterology:
  • Antacids:
    • Preferred regimen (1): Aluminum hydroxide 640 mg 5 to 6 times daily PO after meals and at bed time.
    • Preferred regimen (2): Calcium carbonate One gram PO.
  • Histamine-receptor antagonists (H2RA):
    • Preferred regimen (1): Ranitidine 150 mg q12 daily PO
    • Preferred regimen (2): Cimetidine 400 mg q6h or 800 mg q12 PO for 12 weeks
    • Preferred regimen (3): Famotidine 20 mg q12 PO for 6 weeks
  • Proton pump inhibitors:
    • Preferred regimen (1): Omeprazole 20 mg q24 PO for up to 4 weeks
    • Preferred regimen (2): Esomeprazole 20 mg or 40 mg q24 IV
  • Prokinetic medications:
    • Preferred regimen (1): Metoclopramide 10 mg q24 PO for 4 to 12 weeks

• Infectious esophagitis: Antibiotics, antifungals, or antivirals depending on organism (see regimens below)
• Eosinophilic esophagitis: Topical/systemic corticosteroids (see below)
• Pill esophagitis: Stop offending drug
• Radiation esophagitis: Sucralfate, promotility agents, and viscous lidocaine

Supportive care measures include:

• Acid suppression using proton-pump inhibitors (recommended in all patients)
• Topical pain medications (gargled or swallowed)
• Decreasing or limiting oral intake, total parenteral nutrition (TPN) may be required for advanced cases to allow the esophagus to heal
• Smoking/Alcohol cessation
• Endoscopy to remove any lodged pill fragments

Antimicrobial Regimens

• 1. Candida esophagitis

• Preferred regimen: Fluconazole 100 mg PO qd for 14–21 days OR Itraconazole solution 200 mg PO qd for 14–21 days
• Alternative regimen (1): Itraconazole tablets 200 mg PO qd for 14–21 days
• Alternative regimen (2): Amphotericin B 0.3–0.7 mg/kg/d IV q24h
• Amphotericin B is reserved for patients who have failed therapy with both fluconazole and itraconazole.

• 2. Herpes simplex virus (HSV) esophagitis

• Preferred regimen (1): Acyclovir 5 mg/kg IV q8h for 7–14 days
• Preferred regimen (2): Acyclovir 400 mg 5 times daily PO for 14–21 days
• Preferred regimen (3): Valacyclovir 1 g PO tid for 14–21 days ± maintenance suppressive therapy may be necessary in AIDS
• Alternative regimen (1): Famciclovir 500 mg bid PO for 14–21 days
• Alternative regimen (2): Foscarnet 90 mg/kg q12h IV for 7–14 days

• 3. Cytomegalovirus (CMV) esophagitis

Duration of therapy: 21–42 days or until signs and symptoms have resolved

• Preferred Regimen (1): Ganciclovir 5 mg/kg IV q12h, may switch to valganciclovir 900 mg PO q12h once the patient can absorb and tolerate PO therapy.
• Alternate Regimen (1): Foscarnet 60 mg/kg IV q8h or 90 mg/kg IV q12h for patients with treatment limiting toxicities to ganciclovir or with ganciclovir resistance OR
• Alternate Regimen (2): Oral valganciclovir may be used if symptoms are not severe enough to interfere with oral absorption OR
• Alternate Regimen (3): For mild cases: If ART can be initiated or optimized without delay, withholding CMV therapy may be considered.
  • Note (1): Maintenance therapy is usually not necessary, but should be considered after relapses.

Corticosteroids

• Corticosteroids are recommended in eosinophilic esophagitis.
• First-line regimens include:

• Fluticasone 88–440 mcg PO qd for children, 880–1760 mcg PO qd for adults

OR

• Budesonide 1 mg PO qd for children, 2 mg PO qd for adults

• Patients without symptomatic and histologic improvement after topical steroids may benefit from a longer course or higher doses of topical steroids, systemic steroids with prednisone, dietary elimination, or endoscopic dilation.