What medications are used to treat Gastroesophageal Reflux Disease (GERD)?

Medications for Treating Gastroesophageal Reflux Disease (GERD)

Proton pump inhibitors (PPIs) are the most effective medications for treating GERD and should be used as first-line therapy for patients with typical GERD symptoms. 1 PPIs provide superior acid suppression compared to other medication classes, resulting in better symptom relief and healing rates for erosive esophagitis.

First-Line Therapy: Proton Pump Inhibitors (PPIs)

Available PPIs:

• Omeprazole: 20 mg daily (adults); 0.7-3.3 mg/kg/day (children 2-16 years) 2, 3
• Lansoprazole: 30 mg daily (adults); 0.7-3 mg/kg/day (children 1-17 years) 2
• Esomeprazole: 20-40 mg daily (adults); 0.7-3.3 mg/kg/day (children 1-17 years) 2
• Rabeprazole: 20 mg daily (adults and children 12-17 years) 2, 1
• Pantoprazole: 40 mg daily (adults) 2, 1
• Dexlansoprazole: 30-60 mg daily (adults) 2

Administration:

• Take 30-60 minutes before meals for optimal efficacy (except dexlansoprazole) 1
• Initial treatment duration: 4-8 weeks 2
• For patients with erosive esophagitis, follow-up endoscopy is recommended after 8 weeks of PPI therapy 2

Efficacy:

• PPIs heal erosive esophagitis in 81-91% of patients after 8 weeks compared to 49-63% with H2RAs 4
• PPIs provide complete heartburn resolution in 48% of patients with non-erosive reflux disease compared to 5% with placebo 5
• Omeprazole 20 mg daily is superior to 10 mg daily for symptom relief (74% vs 49% at day 27) 5

Second-Line Therapy: H2 Receptor Antagonists (H2RAs)

• Less effective than PPIs but more effective than placebo 1
• Options include ranitidine, famotidine, cimetidine, and nizatidine 2, 1
• Useful for breakthrough symptoms or as adjuncts to PPIs for nighttime symptoms 1
• Limitations: tachyphylaxis develops within 6 weeks, limiting long-term effectiveness 2

Additional Medication Options:

Antacids

• Provide direct buffering of gastric acid 1
• Best for on-demand, immediate relief rather than daily maintenance therapy 1
• Limited evidence for effectiveness when used alone for daily acid reduction 1

Prokinetic Agents

• Consider for dysmotility-like symptoms (fullness, bloating) 1
• Examples include metoclopramide (limited by side effects)

Baclofen

• Consider for regurgitation or belch-predominant symptoms 1

Treatment Algorithm:

1. Initial Treatment:

   • Start with standard-dose PPI once daily for 4-8 weeks 2
   • Assess response at 4-8 weeks 2

2. If symptoms resolve:

   • Wean to lowest effective dose 2
   • Consider on-demand therapy for patients who can wean 2

3. If partial or no response:

   • Assess compliance
   • Increase to twice-daily PPI or switch to a more effective acid suppressive agent 2
   • Reassess in 4-8 weeks 2

4. For persistent symptoms despite optimization:

   • Consider endoscopy if not previously done 2
   • Consider ambulatory pH monitoring to confirm GERD diagnosis 2
   • Consider adjunctive therapy with H2RAs for nighttime symptoms 1

Special Considerations:

Long-term PPI Use:

• Review ongoing indications for PPI use regularly 1
• Consider de-prescribing for patients without definitive indications for chronic PPI use 1
• Patients on chronic PPI therapy should be offered reflux testing at the 1-year time point to determine appropriateness of long-term therapy 2

PPI Side Effects:

• Potential side effects include headaches, diarrhea, constipation, and nausea (up to 14% of patients) 2
• Long-term risks include bone fractures, kidney problems (tubulointerstitial nephritis), C. difficile infection, and certain types of lupus erythematosus 3
• Take PPIs at the lowest effective dose for the shortest time needed 3

Refractory GERD:

• For patients with persistent symptoms despite PPI therapy, consider:
  • Endoscopy to rule out other conditions 2
  • pH monitoring to confirm acid reflux 2
  • Evaluation for non-GERD causes of symptoms 2
  • Consideration of surgical options in proven GERD cases 2

PPIs remain the cornerstone of GERD treatment due to their superior efficacy in symptom control and healing of esophagitis. Treatment should be tailored based on symptom response, with the goal of using the lowest effective dose to control symptoms and prevent complications.