What is the recommended care plan for Gastroesophageal Reflux Disease (GERD)?

Comprehensive Care Plan for Gastroesophageal Reflux Disease (GERD)

The recommended care plan for GERD should follow a step-wise approach starting with lifestyle modifications and proton pump inhibitors (PPIs) for 8-12 weeks as first-line therapy, followed by maintenance therapy or consideration of surgical options for refractory cases. 1

First-Line Treatment Approach

Initial Medication Therapy

• Proton Pump Inhibitors (PPIs): First-line pharmacological treatment
  • Omeprazole 20-40mg daily or lansoprazole 15-30mg daily for 8-12 weeks 1, 2, 3
  • May need to be titrated up to twice daily dosing if symptoms persist
  • Minimum 8-12 weeks of therapy is often needed; some patients require several months before improvement 1

Concurrent Lifestyle and Dietary Modifications

• Weight loss for overweight or obese patients 1
• Dietary restrictions:
  • Limit fat to no more than 45g in 24 hours
  • Eliminate trigger foods: coffee, tea, soda, chocolate, mints, citrus products, alcohol 1, 4, 5
• Eating habits:
  • Avoid eating 2-3 hours before lying down 1
  • Consider two meals a day with only fluids in between meals to reduce TLESRs 6
• Sleep positioning:
  • Elevate head of bed for nocturnal symptoms 1
  • Sleep on left side to reduce nocturnal reflux 1
• Other modifications:
  • Stop smoking
  • Limit vigorous exercise that increases intra-abdominal pressure 1

Breakthrough Symptom Management

• Antacids (like Mylanta) provide rapid symptom relief when taken in response to symptoms 1
• Alginate-antacid combinations can be used for post-prandial and nighttime breakthrough symptoms 1
• H2-receptor antagonists can be added for nighttime symptoms, though tachyphylaxis may limit long-term use 1

Assessment of Treatment Response and Further Management

If Symptoms Persist After Initial Treatment

1. Consider extending PPI therapy for an additional 4 weeks if partial response 1, 2
2. Consider PPI dose escalation to twice daily if symptoms persist 1
3. Add H2-receptor antagonists for nighttime symptoms 1

Diagnostic Testing for Refractory Cases

• Upper endoscopy to evaluate for:
  • Erosive esophagitis
  • Barrett's esophagus
  • Hiatal hernia 1
• 24-hour pH or impedance-pH monitoring to confirm GERD diagnosis when endoscopy is negative 1
• Prolonged wireless pH monitoring off PPI therapy (96-hour preferred) 1

Management of Refractory GERD

For Confirmed Refractory GERD

Consider surgical interventions:

• Laparoscopic fundoplication (partial fundoplication preferred in patients with esophageal hypomotility) 1
• Magnetic sphincter augmentation (often combined with crural repair for hiatal hernia) 1
• Transoral incisionless fundoplication for carefully selected patients 1
• Roux-en-Y gastric bypass for obese patients with refractory GERD 1

For Behavioral Components

• Consider referral to behavioral therapist for:
  • Hypnotherapy
  • Cognitive behavioral therapy
  • Diaphragmatic breathing
  • Relaxation strategies 1

Special Considerations

Long-term PPI Use Concerns

• Monitor for potential side effects:
  • Impaired cognition
  • Bacterial gastroenteritis
  • Pneumonia
  • Drug interactions
  • Hip fractures
  • Vitamin B12 deficiency
  • Hypomagnesemia
  • Chronic kidney disease 1

Pregnancy

• First-line: Lifestyle and dietary modifications
• Step-up medication approach:
  1. Antacids
  2. Sucralfate
  3. H2-receptor antagonists
  4. PPIs for refractory cases 1

Common Pitfalls to Avoid

• Assuming GERD is ruled out if initial PPI therapy fails 1
• Failing to address both postnasal drip and GERD components simultaneously 1
• Overuse of PPIs in patients without documented GERD or with LPR symptoms alone 1
• Not confirming GERD diagnosis with objective testing before considering surgical interventions 1
• Neglecting to assess esophageal peristaltic function before invasive antireflux procedures 1

Maintenance Therapy

• For patients who respond to initial therapy but have recurrent symptoms:
  • Consider maintenance PPI therapy at the lowest effective dose 1, 2, 3
  • Continue lifestyle and dietary modifications 1
  • Regular follow-up to assess need for continued therapy 1