What is the treatment for Gastroesophageal Reflux Disease (GORD)?

Treatment of Gastroesophageal Reflux Disease (GORD)

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

Step-wise Management Approach

First-line Treatment

1. Lifestyle Modifications

   • Weight reduction for overweight/obese patients (dose-dependent association with symptom reduction) 2, 1
   • Elevate head of bed by 6-8 inches 1
   • Avoid food intake 2-3 hours before lying down 1
   • Limit fat intake to <45g/day 1
   • Avoid trigger foods: coffee, tea, soda, chocolate, mints, citrus, alcohol 1
   • Smoking cessation 1
   • Left lateral decubitus position for sleeping 1
   • Limit vigorous exercise that increases intra-abdominal pressure 1

2. Initial Medication Therapy

   • PPI therapy for 4-8 weeks 2, 3, 4
     • Standard once-daily dosing (e.g., omeprazole, lansoprazole)
     • Take 30-60 minutes before meals for optimal effect
     • Most patients heal within 4 weeks, some may require additional 4 weeks 3

For Partial Response or Persistent Symptoms

1. Optimize PPI therapy

   • Increase to twice-daily dosing 2, 1
   • Switch to a more potent PPI 2

2. Add-on Therapy

   • Add H2RAs (e.g., ranitidine, famotidine) 2, 1
   • Add alginates to PPI therapy 2, 1
   • Consider baclofen as add-on therapy (reduces reflux episodes but has side effects including somnolence, dizziness) 2

For Refractory GORD (No Response After 8-12 Weeks)

1. Diagnostic Reassessment

   • Endoscopy to assess for erosive disease or Barrett's esophagus 2
   • pH monitoring or impedance-pH testing to quantify reflux and assess symptom correlation 2
   • Rule out other conditions (functional heartburn, achalasia) 2

2. Advanced Treatment Options

   • For confirmed refractory GORD:
     • Surgical options for patients with objectively documented GORD 2, 1
       • Laparoscopic fundoplication (consider partial fundoplication for patients with esophageal hypomotility) 2
       • Magnetic sphincter augmentation 2
       • Roux-en-Y gastric bypass (for obese patients) 2
     • Endoscopic options
       • Transoral incisionless fundoplication (for selected patients without hiatal hernia) 2

Special Considerations

Functional Heartburn

• For patients with normal endoscopy, normal acid exposure, and negative symptom association:
  • Consider tricyclic antidepressants or selective serotonin reuptake inhibitors 2
  • Cognitive behavioral therapy may be beneficial 1

Extra-esophageal Symptoms

• Patients with extra-esophageal symptoms (cough, hoarseness, asthma) may require longer treatment (up to 3 months) 1
• If no response after 12 weeks, investigate for non-GORD causes 2, 1

Common Pitfalls to Avoid

1. Inadequate duration of therapy - Improvement in laryngeal symptoms may take up to 3 months 1
2. Overuse of PPIs without documented GORD 1
3. Failure to implement comprehensive lifestyle modifications alongside medication 1
4. Ignoring potential side effects of long-term PPI use - including bacterial gastroenteritis, pneumonia, vitamin B12 deficiency, hypomagnesemia, and chronic kidney disease 1
5. Empiric PPI treatment without proper diagnostic evaluation in refractory cases 1

Monitoring and Long-term Management

• After initial healing, titrate PPI to lowest effective dose 2
• For patients with severe GORD, erosive esophagitis, or Barrett's esophagus, long-term maintenance therapy is typically required 2, 1
• Regular reassessment of symptoms and need for continued therapy 2

Remember that GORD is often a chronic condition requiring long-term management strategies. The goal is to control symptoms, heal esophagitis when present, prevent complications, and improve quality of life.