Treatment of Gastroesophageal Reflux Disease (GERD)
Proton pump inhibitors (PPIs) are the most effective first-line pharmacological treatment for GERD, superior to histamine-2 receptor antagonists (H2RAs) and placebo, and should be initiated as empiric therapy for typical GERD symptoms without the need for initial endoscopy. 1, 2
Initial Approach and Lifestyle Modifications
- Weight loss should be recommended for all overweight or obese patients with GERD 1, 2
- Elevate the head of the bed 6-8 inches for patients with nighttime symptoms or regurgitation when recumbent 1, 2
- Avoid lying down for 2-3 hours after meals to reduce esophageal acid exposure 1, 2
- Avoid trigger foods on an individualized basis (e.g., coffee, chocolate, alcohol, spicy foods, citrus, tomatoes) 1
- Limit fat intake to less than 45g per day as part of an antireflux diet 1
- Avoid smoking and limit alcohol consumption as these can worsen GERD symptoms 1, 3
Pharmacologic Treatment Algorithm
Step 1: Initial Therapy
- Begin with a 4-8 week trial of single-dose PPI therapy (e.g., omeprazole, lansoprazole) 2, 4, 5
- PPIs should be taken 30-60 minutes before meals for optimal effect 2
- Omeprazole is indicated for the treatment of heartburn and other symptoms associated with GERD for up to 4 weeks 4
- Lansoprazole is indicated for short-term treatment (up to eight weeks) for the treatment of heartburn and other symptoms associated with GERD 5
Step 2: Assess Response and Adjust Therapy
- For persistent symptoms despite standard PPI therapy, increase to twice-daily PPI dosing 1, 2
- Consider switching to a more potent acid suppressive agent if symptoms persist 2
- After symptom control is achieved, titrate to the lowest effective PPI dose 1, 2
- H2RAs (ranitidine, famotidine) can be used as add-on therapy to PPI, particularly for nighttime symptoms 2
- Antacids and alginates can provide rapid, short-term relief of breakthrough symptoms 2, 6
Management of Refractory GERD
- If symptoms persist despite optimized PPI therapy, endoscopy should be performed to assess for erosive disease or alternative diagnoses 1, 2
- Adding prokinetic therapy to PPI treatment may be considered for patients with persistent symptoms despite optimized PPI therapy 1
- Implementing a strict antireflux diet (≤45g fat/day, no coffee, tea, soda, chocolate, mints, citrus products, alcohol) may be considered for patients with persistent symptoms 1
- Adding bedtime H2RA (though tachyphylaxis may develop with continued use) can be considered 2
- Consider baclofen as add-on therapy to PPI in selected cases, though limited by side effects including somnolence and dizziness 2, 6
- Avoid using metoclopramide as monotherapy or adjunctive therapy for GERD due to unfavorable risk-benefit profile 1
Special Considerations for Extraesophageal GERD
- More intensive therapy, including twice-daily PPI dosing for 8-12 weeks, may be required for patients with extraesophageal GERD symptoms (chronic cough, laryngitis, asthma) 1
- Response rates to PPI therapy are lower for extraesophageal symptoms compared to typical GERD symptoms 1
- Address comorbid conditions that may worsen GERD, such as sleep apnea 1
Surgical Options
- Antireflux surgery (laparoscopic fundoplication) may be considered for patients with objectively documented GERD that fails maximal medical therapy for at least 3 months 1, 7
- Surgery should be considered only after thorough and objective assessments, particularly in young and healthy patients 7
Long-term Management Considerations
- Periodically reassess the need for continued PPI therapy to minimize potential long-term risks 1, 2, 7
- If long-term PPI therapy is planned, objective reflux testing should be offered to confirm the GERD diagnosis 2
- For functional heartburn (normal acid exposure, negative symptom association), consider neuromodulators (tricyclic antidepressants, selective serotonin reuptake inhibitors) 2
- After initial symptom control with PPI, most patients with esophagitis will experience a relapse within 30 weeks if therapy is discontinued 8