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Erosive esophagitis — Clinical Guidelines

Overview

Erosive esophagitis (EE) is characterized by mucosal damage to the esophageal lining due to chronic acid reflux, often leading to symptoms such as heartburn and dysphagia. 1 2

Diagnosis

Endoscopic confirmation of mucosal breaks is essential.

Grading typically follows the Los Angeles Classification system (LA Class A-D).

Symptom assessment including heartburn and regurgitation severity. 1

Management

First-line treatments:

- Potassium-competitive acid blockers (P-CABs): Fexuprazan 40 mg once daily for 4-8 weeks shows noninferior efficacy to esomeprazole 40 mg once daily. 1 - Proton pump inhibitors (PPIs): Esomeprazole 40 mg once daily is a standard option.

Adjunctive treatments:

- Histamine-2 receptor antagonists (H2RAs) may be used in maintenance therapy, with high-dose strategies showing less effectiveness compared to PPIs. 4 - Vonoprazan (a P-CAB) demonstrates superior early symptom resolution compared to PPIs, particularly beneficial for rapid symptom relief. 3

Special Populations

Pregnancy: Specific guidelines for EE management during pregnancy are not detailed in provided abstracts. 2

Pediatrics: No specific data provided in the abstracts regarding pediatric management. 2

Elderly: No distinct recommendations varying from general adult guidelines are noted. 2

Comorbidities: No specific adjustments for comorbidities are detailed; however, cost-effectiveness analysis suggests PPIs may be more beneficial despite higher costs. 4

Key Recommendations

Fexuprazan 40 mg once daily is a viable first-line treatment option for erosive esophagitis, demonstrating noninferior efficacy to esomeprazole 40 mg once daily for healing (Evidence: Strong 1).

For rapid symptom relief, vonoprazan may be preferred over PPIs, particularly within the first week of treatment (Evidence: Moderate 3).

In maintenance therapy, high-dose H2RAs are less effective and more costly compared to PPIs, suggesting PPIs as a more cost-effective option despite higher costs (Evidence: Moderate 4).

References

1 Zhuang Q, Liao A, He Q, Liu C, Zheng C, Li X et al.. The efficacy and safety of fexuprazan in treating erosive esophagitis: a phase III, randomized, double-blind, multicenter study. Journal of gastroenterology and hepatology 2024. link 2 Pandolfino JE, Spechler SJ, Yadlapati R. Updates in the Management of Erosive Esophagitis. The Journal of family practice 2023. link 3 Oshima T, Igarashi A, Nakano H, Deguchi H, Fujimori I, Fernandez J. Network Meta-analysis Comparing Vonoprazan and Proton Pump Inhibitors for Heartburn Symptoms in Erosive Esophagitis. Journal of clinical gastroenterology 2022. link 4 Harris RA, Kuppermann M, Richter JE. Proton pump inhibitors or histamine-2 receptor antagonists for the prevention of recurrences of erosive reflux esophagitis: a cost-effectiveness analysis. The American journal of gastroenterology 1997. link

Erosive esophagitis