From the Guidelines
The next step for a patient with persistent GERD symptoms despite proton pump inhibitor and H2 blocker therapy is to undergo objective reflux testing, specifically upper GI endoscopy, to establish a diagnosis of GERD and guide long-term management. This approach is supported by the 2022 clinical practice update on the personalized approach to the evaluation and management of GERD, which recommends objective testing with upper GI endoscopy in patients with PPI non-response, presence of alarm signs/symptoms, isolated extra-esophageal symptoms, or in patients who meet criteria to undergo screening for Barrett’s esophagus 1.
Key considerations for this patient include:
- The presence of persistent symptoms despite adequate proton pump inhibitor and H2 blocker therapy, which suggests the need for further evaluation to identify the underlying cause of symptoms
- The importance of establishing a diagnosis of GERD and guiding long-term management, which may involve escalation of therapy, lifestyle modifications, or other interventions
- The potential for underlying conditions such as erosive esophagitis, Barrett’s esophagus, or functional esophageal disorders, which may require specific treatment beyond acid suppression
In patients without erosive disease on endoscopy and with physiologic acid exposure, prolonged wireless pH monitoring off PPI therapy can be utilized to assess esophageal acid exposure 1. However, for patients with persistent symptoms despite PPI therapy, upper GI endoscopy is the preferred next step to guide further management and rule out underlying conditions that may be contributing to symptoms. This approach prioritizes the patient's morbidity, mortality, and quality of life by ensuring that underlying conditions are identified and treated appropriately, rather than simply escalating medication dosage or continuing ineffective therapy.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Next Steps for Patients with Persistent GERD Symptoms
For patients with persistent GERD symptoms despite proton pump inhibitor (PPI) and H2 blocker therapy, the following options can be considered:
- Increasing the dose of the current PPI or switching to a different PPI, as some studies have shown that increasing the dose or switching to a more potent PPI can improve symptoms 2
- Adding a prokinetic agent to the treatment regimen, although the evidence for this approach is limited and inconclusive 3, 4, 5
- Considering alternative diagnoses or underlying conditions that may be contributing to the persistent symptoms
Treatment Options
The following treatment options have been studied for patients with persistent GERD symptoms:
- Esomeprazole 40 mg, which has been shown to significantly improve symptoms in patients with persistent GERD symptoms despite full-dose PPI therapy 2
- Pantoprazole, which has been shown to be effective in the management of patients with GERD, including those with refractory symptoms 6
- Other PPIs, such as omeprazole, lansoprazole, and rabeprazole, which have been shown to be effective in the treatment of GERD, although the evidence for their use in patients with persistent symptoms despite PPI and H2 blocker therapy is limited 3, 4, 5
Comparison of Treatment Options
The following comparisons have been made between different treatment options:
- PPIs vs. H2RAs: PPIs have been shown to be more effective than H2RAs in relieving heartburn in patients with GERD, including those with persistent symptoms despite PPI and H2 blocker therapy 3, 4, 5
- PPIs vs. prokinetics: PPIs have been shown to be more effective than prokinetics in relieving heartburn in patients with GERD, although the evidence for this comparison is limited 3, 4, 5