What is the initial management for a patient with epigastric pain that worsens with lying down, suspected to be related to gastroesophageal reflux disease (GERD) or peptic ulcer disease (PUD)?

From the Guidelines

Initial management for a patient with epigastric pain worsening when lying down, likely due to GERD or PUD, should begin with lifestyle modifications and medication therapy, prioritizing proton pump inhibitors (PPIs) such as omeprazole 20-40mg once daily or pantoprazole 40mg once daily, taken 30 minutes before breakfast for 4-8 weeks, as recommended by the most recent guidelines 1.

Key Lifestyle Modifications

• Avoid trigger foods (spicy, fatty, acidic)
• Stop smoking
• Reduce alcohol consumption
• Eat smaller meals
• Maintain a healthy weight
• Elevate the head of the bed by 6-8 inches

Medication Therapy

• First-line: Proton pump inhibitors (PPIs) such as omeprazole or pantoprazole
• Alternatives: H2-receptor antagonists like ranitidine or famotidine
• Antacids (Maalox, Mylanta) for rapid but short-term relief

Additional Considerations

• If H. pylori infection is suspected in PUD, testing should be performed, followed by triple therapy if positive: a PPI twice daily plus amoxicillin and clarithromycin for 14 days, as supported by evidence 1.
• Patients should be advised to seek immediate medical attention if they experience alarm symptoms such as weight loss, vomiting, bleeding, or severe pain unresponsive to treatment.
• The most recent guidelines emphasize a personalized approach to the evaluation and management of GERD, including a stepwise diagnostic approach and a shared decision-making model with the patient 1.

From the FDA Drug Label

Treatment of Symptomatic GERD 20 mg once daily Up to 4 weeks Treatment of EE due to Acid-Mediated GERD 20 mg once daily 4 to 8 weeks The initial management for a patient with epigastric pain that worsens with lying down, suspected to be related to gastroesophageal reflux disease (GERD) or peptic ulcer disease (PUD), is omeprazole 20 mg once daily for up to 4 weeks for symptomatic GERD or 4 to 8 weeks for EE due to acid-mediated GERD 2.

• Key considerations:
  • Take omeprazole delayed-release capsules before meals.
  • Antacids may be used concomitantly with omeprazole delayed-release capsules.
  • Missed doses should be administered as soon as possible, but not two doses at one time.
• Important safety information: Omeprazole delayed-release capsules can cause serious side effects, including a type of kidney problem, diarrhea, and bone fractures 2.

From the Research

Initial Management for Epigastric Pain

The initial management for a patient with epigastric pain that worsens with lying down, suspected to be related to gastroesophageal reflux disease (GERD) or peptic ulcer disease (PUD), involves several key considerations:

• Proton Pump Inhibitors (PPIs): PPIs, such as omeprazole, are commonly used to reduce gastric acid secretion and are effective in treating GERD and PUD 3.
• Symptom Management: For patients with heartburn and normal endoscopy who failed once daily PPIs, fluoxetine may be considered as an alternative treatment option, as it has been shown to be superior to omeprazole in achieving symptomatic relief 4.
• Gastric Emptying: PPIs can delay gastric emptying of solids, which may have clinical implications in the management of GERD and functional dyspepsia 5.
• Alternative Treatments: Mucosal protective agents, such as Poliprotect, have been shown to be noninferior to omeprazole in relieving heartburn and epigastric pain/burning in patients without erosive esophagitis and gastroduodenal lesions 6.

Treatment Options

Treatment options for epigastric pain that worsens with lying down may include:

• Omeprazole: 10-40 mg/day for adults and 10-20 mg/day for children 3.
• Fluoxetine: may be considered for patients with heartburn and normal endoscopy who failed once daily PPIs 4.
• Poliprotect: a mucosal protective agent that has been shown to be noninferior to omeprazole in relieving heartburn and epigastric pain/burning 6.
• Lifestyle Modifications: avoiding triggers that worsen symptoms, such as lying down after eating, and making dietary changes to reduce acid reflux.

Considerations

When managing epigastric pain that worsens with lying down, it is essential to consider the potential effects of PPIs on gastric emptying and the role of alternative treatments, such as fluoxetine and Poliprotect, in achieving symptomatic relief 3, 4, 5, 6.