What is the most appropriate intervention for a 52-year-old female with symptoms of gastroesophageal reflux disease (GERD), including acidic taste, heartburn, and regurgitation, who has not responded to antacids?

Management of GERD in a Patient with Persistent Symptoms Despite Antacids

Initiate esomeprazole 20 mg orally once daily is the most appropriate intervention for this 52-year-old female with persistent GERD symptoms not responding to antacids.

Clinical Assessment

The patient presents with classic GERD symptoms:

• Acidic taste in mouth
• Heartburn
• Intermittent regurgitation
• Symptoms occurring most days of the week for 4 weeks
• Inadequate response to antacids

These symptoms are consistent with gastroesophageal reflux disease (GERD) that requires more effective acid suppression than what antacids can provide.

Treatment Recommendation

First-Line Therapy

• Proton pump inhibitor (PPI) therapy is the first-line treatment for patients with GERD symptoms not responding to antacids 1, 2
• Standard-dose PPI once daily, taken 30-60 minutes before a meal, is recommended as initial therapy 2
• A 4-8 week trial is appropriate for initial management 1

Why Esomeprazole 20 mg Once Daily?

1. PPIs are significantly more effective than H2-receptor antagonists (like famotidine) for both symptom relief and healing in GERD 2, 3
2. Once-daily dosing is appropriate for initial therapy before considering twice-daily dosing 1
3. The standard dose of esomeprazole (20 mg) is appropriate for initial management of GERD symptoms 2

Why Not Other Options?

1. Famotidine 10 mg twice daily:

   • H2-receptor antagonists are less effective than PPIs for GERD management 2, 3
   • H2-receptor antagonists have shorter duration of action and provide incomplete inhibition of meal-stimulated acid secretion 3

2. Omeprazole 20 mg twice daily:

   • Twice-daily PPI therapy is recommended only after failure of once-daily dosing 1
   • The American Gastroenterological Association recommends starting with standard-dose PPI once daily before escalating to twice-daily dosing 2

3. Endoscopy before medication:

   • Endoscopy is not indicated as the first step for patients with typical GERD symptoms without alarm features 1
   • The American College of Physicians recommends an initial trial of empirical PPI therapy before considering endoscopy 1
   • Endoscopy should be considered only after failure of twice-daily PPI therapy 1

Follow-up Plan

1. Evaluate symptomatic response after 4-8 weeks 2

   • If complete resolution: consider reducing to lowest effective dose
   • If partial response: consider increasing to twice-daily dosing
   • If no response: consider alternative diagnoses and perform endoscopy

2. Lifestyle modifications to recommend alongside PPI therapy:

   • Weight management if overweight/obese
   • Elevating the head of the bed for nighttime symptoms
   • Avoiding meals within 3 hours of bedtime
   • Avoiding specific trigger foods based on patient history 2

Important Considerations

• PPIs are safe for appropriate use in GERD management 1
• If symptoms persist despite 4-8 weeks of once-daily PPI therapy, consider increasing to twice-daily dosing before pursuing diagnostic testing 1
• Endoscopy should be reserved for patients who have not responded to an empirical trial of twice-daily PPI therapy or who have alarm symptoms such as dysphagia 1

This approach prioritizes effective symptom control while following a stepwise approach that reserves more intensive interventions for those who fail initial therapy.