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

From the Guidelines

The treatment of Gastroesophageal Reflux (GER) Disease should prioritize a personalized approach, with proton pump inhibitors (PPIs) as the mainstay of pharmacologic therapy, and lifestyle modifications, including weight management and cognitive behavioral therapy, as essential components of management. According to the most recent and highest quality study 1, acid suppression with PPIs is effective for healing of erosive esophagitis and controlling typical symptoms of GERD. The study suggests that twice daily PPI is superior to once daily PPI in gastric acid suppression and likely more effective for extraesophageal reflux (EER) symptoms.

Key Components of GERD Management

• PPI therapy: up to twice daily dosing for 8-12 weeks in empiric treatment, to address extraesophageal symptoms in patients with concomitant EER and esophageal reflux symptoms, or in those with pathologic reflux documented through objective testing 1
• Lifestyle modifications: weight management, cognitive behavioral therapy, and gut-directed hypnotherapy to reduce symptoms and improve quality of life 1
• Objective testing: upper GI endoscopy, esophageal physiologic testing, and pH-impedance monitoring to establish a diagnosis of GERD and guide long-term management 1

Special Considerations

• Erosive esophagitis: requires continuous long-term PPI therapy or invasive anti-reflux procedures, in addition to optimization of lifestyle measures 1
• Non-erosive reflux disease: may respond well to optimization of lifestyle and pharmacotherapy, and may ultimately be able to wean pharmacotherapy down to the lowest effective dose 1
• Extraesophageal reflux: may require twice daily PPI therapy, and non-PPI treatment options such as alginate-containing antacids, neuromodulators, cognitive behavioral therapy, and hypnotherapy may have a role in reducing symptoms 1

From the FDA Drug Label

1. Treatment of GERD. Symptomatic relief commonly occurs within 24 hours after starting therapy with ranitidine 150 mg twice daily.
2. 4 Treatment of Symptomatic Gastroesophageal Reflux Disease (GERD) Omeprazole delayed-release capsules are indicated for the treatment of heartburn and other symptoms associated with GERD for up to 4 weeks in patients 2 years of age and older.

The treatment for Gastroesophageal Reflux (GER) Disease includes:

• Ranitidine 150 mg twice daily for symptomatic relief of GERD, which can occur within 24 hours of starting therapy 2
• Omeprazole for the treatment of heartburn and other symptoms associated with GERD for up to 4 weeks in patients 2 years of age and older 3

From the Research

Treatment Goals

The primary treatment goals in patients with gastroesophageal reflux disease (GERD) are:

• Relief of symptoms
• Prevention of symptom relapse
• Healing of erosive esophagitis
• Prevention of complications of esophagitis 4, 5, 6

Treatment Options

Treatment options for GERD include:

• Lifestyle modifications (e.g., elevating the head of the bed, modifying the size and composition of meals) 4, 5, 7, 8
• Pharmacologic agents:
  • Histamine H2-receptor antagonists (H2RAs) 4, 5, 8
  • Proton pump inhibitors (PPIs) 4, 5, 6, 7, 8
  • Prokinetic medications (e.g., metoclopramide) 8
  • Baclofen, which inhibits transient lower esophageal sphincter relaxations 8
• Antireflux surgery, including open and laparoscopic versions of Nissen fundoplication 4
• Newer endoscopic modalities, including the Stretta and endocinch procedures 4
• Incisionless laparoscopic fundoplications and newer endoluminal techniques such as the LINX device 7

Treatment Approach

The preferred empiric approach is:

• Step-up therapy (treat initially with an H2RA for eight weeks; if symptoms do not improve, change to a PPI) 4
• Step-down therapy (treat initially with a PPI; then titrate to the lowest effective medication type and dosage) 4
• Long-term medical therapy for GERD should be tailored to each patient to provide symptomatic control and maintain esophageal mucosal healing 8

Special Considerations

• In patients with erosive esophagitis identified on endoscopy, a PPI is the initial treatment of choice 4
• Diagnostic testing should be reserved for patients who exhibit warning signs (i.e., weight loss, dysphagia, gastrointestinal bleeding) and patients who are at risk for complications of esophagitis (i.e., esophageal stricture formation, Barrett's esophagus, adenocarcinoma) 4
• Long-term acid suppressive therapy, as with the use of PPIs, may lead to hypergastrinemia, a situation in which the endocrine cells of the stomach may proliferate 6