What are the treatment recommendations for Non-Erosive Reflux Disease (NERD)?

Treatment Recommendations for Non-Erosive Reflux Disease (NERD)

Proton pump inhibitors (PPIs) are the most effective first-line pharmacologic therapy for NERD, though they are less effective in NERD than in erosive esophagitis, with a short course or as-needed use recommended when symptom control is the primary objective. 1

Initial Approach to NERD Management

Pharmacologic Therapy

1. First-line therapy:

   • Start with a PPI (standard dose, once daily) for 2-4 weeks 2
   • Take PPI 30-60 minutes before the first meal of the day 3
   • PPIs are more effective than H2-receptor antagonists (H2RAs), which are more effective than placebo 1

2. If initial treatment fails:

   • Increase to standard dose PPI twice daily 2
   • Consider adding prokinetic therapy if symptoms persist 1
   • H2RAs or alginates may be added to PPI therapy for additional symptom control 1

Lifestyle Modifications

For selected patients with NERD, the following lifestyle modifications are recommended:

1. Weight loss for overweight or obese patients 1

2. Elevation of the head of the bed for patients with nighttime symptoms 1

3. Dietary modifications:

   • Avoid food intake 2-3 hours before recumbency 1
   • Limit fat intake to no more than 45g in 24 hours 1
   • Avoid trigger foods on an individual basis (common triggers: coffee, alcohol, chocolate, fatty foods, citrus, carbonated drinks, spicy foods) 1

4. Positional changes:

   • Left lateral decubitus position for sleeping 1

Management Algorithm for Refractory NERD

If symptoms persist despite standard therapy:

1. Confirm medication compliance 1

2. Consider diagnostic testing:

   • Upper GI endoscopy to rule out other conditions (eosinophilic esophagitis, infection)
   • 24-hour esophageal impedance and pH monitoring to differentiate:
     • Acid-reflux-related NERD
     • Weakly acid-reflux-related NERD (hypersensitive esophagus)
     • Non-acid-reflux-related NERD
     • Functional heartburn 1, 2

3. Treatment options for refractory cases:

   • Switch to another PPI 1
   • Add baclofen as adjunctive therapy (limited by side effects like somnolence, dizziness) 1
   • Consider antireflux surgery in selected patients with objectively documented reflux 1, 4

Important Considerations

• Only about 50% of patients with NERD have pathologic esophageal acid exposure on 24-hour pH monitoring 4
• NERD patients have similar quality of life decrements as those with erosive esophagitis 4
• Alternative approaches being investigated include two meals a day with only fluids in between to reduce transient lower esophageal sphincter relaxations 5
• Metoclopramide is not recommended as monotherapy or adjunctive therapy for NERD 1

Common Pitfalls

1. Assuming all NERD patients will respond to acid suppression: Up to 50% of NERD patients fail to respond to standard PPI doses due to non-acid reflux, visceral hypersensitivity, or functional heartburn 2, 6

2. Inadequate duration of therapy: Allow 2-4 weeks to assess response before modifying treatment 2

3. Overlooking proper PPI administration: PPIs should be taken 30-60 minutes before meals for optimal effect 3

4. Recommending the same lifestyle modifications for all patients: Tailor lifestyle recommendations to individual patients based on their specific symptoms and triggers 1