Esophagitis medical therapy: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Esophagitis}} | {{Esophagitis}} | ||
{{CMG}} | {{CMG}} {{AE}} {{Ajay}} | ||
==Overview== | ==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]]. | 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== | ==Medical Therapy== | ||
Treatment of esophagitis depends on the underlying cause | 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 [[Pediatrics|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 [[Nutrition|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:<ref>Decktor DL, Robinson M, Maton PN, Lanza FL, Gottlieb S. Effects of Aluminum/Magnesium Hydroxide and Calcium Carbonate on Esophageal and Gastric pH in Subjects with Heartburn. ''Am J Ther'' 1995;2:546-552. PMID 11854825.</ref><ref name="pmid17229239">{{cite journal |author=Tran T, Lowry A, El-Serag H |title=Meta-analysis: the efficacy of over-the-counter gastro-oesophageal reflux disease drugs |journal=Aliment Pharmacol Ther |volume=25 |issue=2 |pages=143-53 |year=2007 |id=PMID 17229239 | doi=10.1111/j.1365-2036.2006.03135.x}}</ref>.<ref>{{Cite journal| doi = 10.1038/ajg.2013.71| issn = 1572-0241| volume = 108| issue = 5| pages = 679–692; quiz 693| last1 = Dellon| first1 = Evan S.| last2 = Gonsalves| first2 = Nirmala| last3 = Hirano| first3 = Ikuo| last4 = Furuta| first4 = Glenn T.| last5 = Liacouras| first5 = Chris A.| last6 = Katzka| first6 = David A.| last7 = American College of Gastroenterology| title = ACG clinical guideline: Evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE)| journal = The American Journal of Gastroenterology| date = 2013-05| pmid = 23567357}}</ref> | |||
* | * '''Reflux esophagitis''' | ||
** '''[[Antacids]]''': | ** '''[[Antacids]]''': | ||
*** Preferred regimen (1): [[Aluminum hydroxide]] 640 mg 5 to 6 times daily PO after meals and at bed time. | *** Preferred regimen (1): [[Aluminum hydroxide]] 640 mg 5 to 6 times daily PO after meals and at bed time. | ||
| Line 44: | Line 34: | ||
*** Preferred regimen (1): [[Metoclopramide]] 10 mg q24 PO for 4 to 12 weeks | *** Preferred regimen (1): [[Metoclopramide]] 10 mg q24 PO for 4 to 12 weeks | ||
*''Infectious esophagitis'' | *'''Infectious esophagitis''' | ||
*'' | **'''1. Candida esophagitis'''<ref>{{cite book | last = Bennett | first = John | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2015 | isbn = 978-1455748013 }}</ref> | ||
*'' | ***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'''<ref>{{cite book | last = Bennett | first = John | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2015 | isbn = 978-1455748013 }}</ref> | |||
***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 {{withorwithout}} 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'''<ref>{{cite book | last = Bennett | first = John | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2015 | isbn = 978-1455748013 }}</ref> | |||
***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|'''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 | |||
*''' | |||
*''' | |||
* | |||
*Preferred | |||
==References== | ==References== | ||
Latest revision as of 17:38, 29 January 2018
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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:[1][2].[3]
- 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
- Antacids:
- Infectious esophagitis
- 1. Candida esophagitis[4]
- 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[5]
- 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[6]
- 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.
- 1. Candida esophagitis[4]
- 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
- Steroid Therapy
References
- ↑ Decktor DL, Robinson M, Maton PN, Lanza FL, Gottlieb S. Effects of Aluminum/Magnesium Hydroxide and Calcium Carbonate on Esophageal and Gastric pH in Subjects with Heartburn. Am J Ther 1995;2:546-552. PMID 11854825.
- ↑ Tran T, Lowry A, El-Serag H (2007). "Meta-analysis: the efficacy of over-the-counter gastro-oesophageal reflux disease drugs". Aliment Pharmacol Ther. 25 (2): 143–53. doi:10.1111/j.1365-2036.2006.03135.x. PMID 17229239.
- ↑ Dellon, Evan S.; Gonsalves, Nirmala; Hirano, Ikuo; Furuta, Glenn T.; Liacouras, Chris A.; Katzka, David A.; American College of Gastroenterology (2013-05). "ACG clinical guideline: Evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE)". The American Journal of Gastroenterology. 108 (5): 679–692, quiz 693. doi:10.1038/ajg.2013.71. ISSN 1572-0241. PMID 23567357. Check date values in:
|date=(help) - ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
- ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
- ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.