Esophagitis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Ajay Gade MD[2]]

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 along with dietary modifications

Dietary Modification

• Elemental diet- highly effective in both adults and children, but it is limited by patient tolerability.
• Empiric six-food elimination diet (SFED)- the most common foods that trigger EoE are: soy, fish, cow milk, nuts, eggs, wheat.
• Limited diet driven by allergy testing and patient history- The allergy testing directs diet approach, although effective in the pediatric group has only moderate success in adults.
• The goal of dietary therapy is identification and removal of food antigens and consequently remove the sensitization.
• Diet therapy gives patients an alternative to control their disease, many patients find the idea of managing their sickness by means of removing the nutritional trigger moe appealing than taking a drug to counteract the downstream inflammatory response.
• It is far vital to emphasize that the stern dietary elimination of multiple foods is only for a limited time but the long-term goal is the identify and remove the triggering dietary elements.
• Prolonged deviation from the elimination diet can be managed via intermittent use of quick courses of topical steroids.

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:.

• Reflux esophagitis
  • 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
  • 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
    • 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.

• Eosinophilic esophagitis
  • Steroid Therapy
    • Preferred regimen (1) : fluticasone 880–1760 mcg PO qd
    • Preferred regimen (2) : Budesonide 1 mg PO qd for children, 2 mg PO qd