What is the appropriate management and treatment of Gastroesophageal Reflux Disease (GERD)?

From the Guidelines

The most effective approach to managing GERD is a step-up approach starting with lifestyle modifications and a trial of over-the-counter antacids, followed by prescription of a proton pump inhibitor if symptoms persist, as recommended by the most recent and highest quality study 1.

Introduction to the Patient

Begin by introducing yourself, confirming the patient's identity, and establishing rapport. The patient is a 45-year-old office worker presenting with burning chest pain after meals, worse when lying down, and occasional regurgitation of sour liquid into the throat for the past 3 months.

History Taking

Take a detailed history focusing on symptom characteristics (onset, duration, frequency, aggravating/relieving factors), associated symptoms (dysphagia, odynophagia, weight loss, hematemesis), and red flags (anemia, dysphagia, weight loss). Ask about lifestyle factors including diet, alcohol, smoking, and medication use. Inquire about previous treatments tried and their effectiveness.

Physical Examination

Perform a focused examination including vital signs, abdominal examination, and cardiorespiratory assessment to rule out cardiac causes.

Diagnosis and Management

Explain your diagnosis of GERD based on typical symptoms and recommend a step-up approach starting with lifestyle modifications (weight loss, avoiding trigger foods, not eating 3 hours before bedtime, elevating the head of the bed) and a trial of over-the-counter antacids, as supported by the AGA clinical practice update 1.

• Lifestyle modifications:
  • Weight loss
  • Avoiding trigger foods
  • Not eating 3 hours before bedtime
  • Elevating the head of the bed
• Trial of over-the-counter antacids

Pharmacological Intervention

If symptoms persist, prescribe a proton pump inhibitor like omeprazole 20mg once daily 30 minutes before breakfast for 4-8 weeks, as recommended by the AGA clinical practice update 1.

Follow-up and Further Investigation

Discuss the need for endoscopy if there are alarm symptoms or if the patient is over 55 with persistent symptoms. Arrange follow-up in 4-8 weeks to assess response to treatment. Explain potential complications of untreated GERD including esophagitis, Barrett's esophagus, and esophageal strictures, as highlighted in the study 1.

Personalized Approach

Consider a personalized approach to the evaluation and management of GERD, taking into account the patient's individual symptoms, medical history, and response to treatment, as recommended by the study 1.

Key Recommendations

• Lifestyle modifications and over-the-counter antacids as first-line treatment 1
• Proton pump inhibitor therapy for persistent symptoms 1
• Endoscopy for alarm symptoms or persistent symptoms in patients over 55 1
• Personalized approach to management 1

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

GERD AMC OSCE Script

Introduction to GERD

• Gastroesophageal reflux disease (GERD) is defined by recurrent and troublesome heartburn and regurgitation or GERD-specific complications 2
• It affects approximately 20% of the adult population in high-income countries 2
• Risk factors for GERD include obesity, tobacco smoking, and genetic predisposition 2

Diagnosis of GERD

• Typical GERD symptoms are often sufficient to determine the diagnosis 2
• Less common symptoms and signs, such as dysphagia and chronic cough, may occur 2
• Patients with typical GERD symptoms can be medicated empirically with a proton pump inhibitor (PPI) 2
• Endoscopy, esophageal manometry, and esophageal pH monitoring are recommended for patients who do not respond to treatment or if the diagnosis is unclear 2

Treatment Options for GERD

• Lifestyle changes, medication, and surgery are the main treatment options for GERD 2
• Weight loss and smoking cessation are often useful 2
• Medication with a PPI is the most common treatment, and after initial full-dose therapy, the aim is to use the lowest effective dose 2
• Surgery with laparoscopic fundoplication is an invasive treatment alternative in select patients after thorough and objective assessments 2
• Endoscopic and less invasive surgical techniques are emerging, which may reduce the use of long-term PPI and fundoplication 2

Management of GERD

• The American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for strategies to diagnose and manage GERD 3
• The ASGE suggests upper endoscopy for the evaluation of GERD in patients with alarm symptoms, with multiple risk factors for Barrett's esophagus, and with a history of sleeve gastrectomy 3
• The ASGE recommends careful endoscopic evaluation, reporting, and photo-documentation of objective GERD findings with attention to gastroesophageal junction landmarks and integrity in patients who undergo upper endoscopy 3
• In patients with GERD symptoms, the ASGE recommends lifestyle modifications 3
• In patients with symptomatic and confirmed GERD with predominant heartburn symptoms, the ASGE recommends medical management including PPIs at the lowest dose for the shortest duration possible while initiating discussion about long-term management options 3

Comparison of Treatment Options

• The newer proton pump inhibitors (PPIs) lansoprazole, rabeprazole, and pantoprazole are of similar efficacy to omeprazole in terms of heartburn control, healing rates, and relapse rates 4
• All the PPIs are superior to ranitidine and placebo in healing erosive esophagitis and decreasing relapse rates 4
• A clinical decision analysis comparing a PPI, lansoprazole and a histamine H2-receptor antagonist (H2RA), ranitidine for the treatment of reflux esophagitis in Japan found that the PPI was consistently superior to the H2RA with regard to both clinical effectiveness and cost-effectiveness 5