What are the recommended treatments for gastroesophageal reflux disease (GERD)?

Recommended Treatments for Gastroesophageal Reflux Disease (GERD)

Proton pump inhibitors (PPIs) are the most effective first-line treatment for GERD, with superior efficacy compared to histamine-2 receptor antagonists (H2RAs) and placebo for both healing esophagitis and symptom relief. 1, 2

Pharmacological Treatment Algorithm

First-Line Therapy

• PPI therapy: Start with a standard once-daily dose taken 30-60 minutes before the first meal of the day for 4-8 weeks 2
  • Any commercially available PPI can be used (omeprazole, lansoprazole, etc.) 2, 3, 4
  • PPIs are indicated for treatment of heartburn and other symptoms associated with GERD for up to 4 weeks 3, 4

For Inadequate Response to Once-Daily PPI

1. Confirm proper PPI administration (30-60 minutes before meals) 2
2. Increase to twice-daily PPI dosing 1, 2
3. Consider switching to another PPI if side effects occur (headache, diarrhea, constipation, abdominal pain) 1

For Persistent Symptoms Despite Optimized PPI Therapy

• Consider patients with inadequate response to twice-daily PPI as treatment failures 1
• Perform diagnostic testing (endoscopy, pH monitoring) to confirm GERD diagnosis 1, 2
• Consider antireflux surgery in selected patients with objectively documented reflux 1

Alternative/Adjunctive Medications

• H2RAs: Effective but less potent than PPIs; can be used for short-term or on-demand therapy 1, 2
• Antacids: Provide rapid but short-term symptom relief; can be combined with H2RAs or PPIs for on-demand therapy 1
• Alginates: May be added to PPI therapy for additional symptom control 2

Important: Metoclopramide is NOT recommended as monotherapy or adjunctive therapy for GERD due to evidence of ineffectiveness or potential harm outweighing benefits 1

Lifestyle Modifications

Strongly Recommended Interventions

• Weight loss for overweight or obese patients 1, 2, 5
  • Shows dose-dependent association with reduction of GERD symptoms 1
  • Decreases time with esophageal acid exposure 5
• Elevation of the head of the bed for patients with nighttime symptoms 1, 2, 5
  • Decreases time with supine acid exposure from 21% to 15% 5

Individualized Recommendations Based on Symptom Patterns

• Avoid late evening meals (reduces supine acid exposure) 5
• Avoid specific trigger foods based on consistent symptom patterns 1, 6
  • Common triggers: fatty/fried foods, citrus juices, tomatoes, chocolate, coffee/tea, carbonated beverages, spicy foods 6
• Avoid recumbency for 2-3 hours after meals 1, 2
• Smoking cessation (reduces reflux symptoms, particularly in normal-weight individuals) 5

Long-Term Management

• Taper PPI to lowest effective dose after symptom control is achieved 2
• Consider routine re-evaluation of treatment within 12 months 2
• For maintenance of healing of erosive esophagitis, continued PPI therapy may be necessary 3, 4

Common Pitfalls to Avoid

1. Inadequate PPI dosing or timing (must be taken before meals) 2
2. Failure to implement appropriate lifestyle modifications 2
3. Overreliance on antacids alone for chronic GERD management 2
4. Not recognizing extra-esophageal manifestations of GERD (chronic cough, laryngitis, globus sensation) 7
5. Continuing metoclopramide despite evidence against its use 1

Special Considerations

• For patients with erosive esophagitis identified on endoscopy, PPI is the initial treatment of choice 8
• For nocturnal GERD, head-of-bed elevation and avoiding late evening meals are particularly effective 5
• For patients with functional heartburn (normal endoscopy, pH testing, and negative symptom association), consider low-dose pain modulators such as tricyclic antidepressants 1

By following this evidence-based approach to GERD management, clinicians can effectively control symptoms, heal esophagitis, and prevent complications while minimizing unnecessary medication use and invasive procedures.