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

Treatment of Gastroesophageal Reflux Disease (GERD)

The first-line treatment for GERD is proton pump inhibitors (PPIs), which are more effective than histamine-2 receptor antagonists (H2RAs) and placebo for healing esophagitis and controlling symptoms. 1, 2

Initial Management Approach

Lifestyle Modifications

• Weight loss should be recommended for all overweight or obese patients with GERD 2, 3
• Elevate the head of the bed 6-8 inches for patients with nighttime symptoms or regurgitation when recumbent 2, 1
• Avoid lying down for 2-3 hours after meals to reduce esophageal acid exposure 2, 3
• Avoid specific trigger foods that consistently worsen symptoms (e.g., coffee, alcohol, spicy foods, chocolate, mints, citrus products) 1, 3
• Limit fat intake to no more than 45g in 24 hours for patients requiring intensive treatment 1
• Avoid smoking and limit vigorous exercise that increases intraabdominal pressure 1

Pharmacologic Therapy

• For patients with typical GERD symptoms without alarm features, start with a 4-8 week trial of single-dose PPI 1, 3
• PPIs should be taken 30-60 minutes before meals for optimal effect 3, 4
• If symptoms persist despite standard PPI therapy, increase to twice-daily PPI dosing 1, 2
• H2RAs can be used as add-on therapy to PPI, particularly for nighttime symptoms, though tachyphylaxis may develop with continued use 3, 5
• Antacids provide rapid but short-term relief of breakthrough symptoms 5, 6
• After symptom control is achieved, titrate to the lowest effective PPI dose 2, 3

Management of Refractory GERD

Diagnostic Evaluation

• Consider endoscopy after failed empiric therapy to assess for esophagitis or other pathology 1, 2
• In the absence of erosive disease on endoscopy, consider prolonged wireless pH monitoring off PPI therapy to confirm GERD diagnosis 1, 3

Treatment Options for Refractory GERD

• Optimize PPI therapy (timing, compliance, dosing) 3, 6
• Consider adding prokinetic therapy to PPI and lifestyle modifications 1
• For patients with extraesophageal GERD symptoms, more intensive therapy may be required, including PPI twice daily and a strict antireflux diet 1, 2
• Address comorbid conditions that may worsen GERD, such as sleep apnea 1

Surgical and Endoscopic Options

• For patients with proven GERD that has failed maximal medical therapy, consider surgical options 1
• Laparoscopic fundoplication is effective in non-obese patients; type of fundoplication may be tailored based on esophageal motility 1, 6
• Magnetic sphincter augmentation is an option, often combined with crural repair for hiatal hernia 1, 6
• Transoral incisionless fundoplication is an endoscopic option for carefully selected patients without hiatal hernia 1, 6
• Roux-en-Y gastric bypass is effective for obese patients with GERD, while sleeve gastrectomy may worsen GERD 1, 6

Long-term Management Considerations

• Periodically reassess the need for continued PPI therapy and attempt to use the lowest effective dose 2, 3
• If long-term PPI therapy is planned, objective reflux testing should be offered to establish a GERD diagnosis 1, 3
• For patients with erosive esophagitis or Barrett's esophagus, long-term PPI therapy is indicated 4, 7

Common Pitfalls and Caveats

• Metoclopramide should not be used as monotherapy or adjunctive therapy for GERD due to unfavorable risk-benefit profile 1, 2
• Empirical PPI therapy should not exceed twice-daily dosing for 8-12 weeks before considering endoscopic evaluation 1, 3
• Patients with alarm symptoms (dysphagia, weight loss, anemia, gastrointestinal bleeding) require prompt endoscopic evaluation rather than empiric therapy 1, 4
• Failure to respond to PPI therapy does not rule out GERD; consider inadequate therapy or need for objective testing 1