Treatment Options for Gastroesophageal Reflux Disease (GERD)
Proton pump inhibitors (PPIs) are the most effective first-line pharmacological treatment for patients with GERD, superior to histamine-2 receptor antagonists (H2RAs) and placebo. 1
Initial Treatment Approach
Lifestyle Modifications
- Weight loss should be recommended for all overweight or obese patients with GERD 1, 2
- Elevation of the head of bed (6-8 inches) is recommended for patients with nighttime symptoms or regurgitation when recumbent 1, 3
- Avoid lying down for 2-3 hours after meals to reduce esophageal acid exposure 1, 3
- Implement an antireflux diet that includes limiting fat intake to less than 45g per day 4, 1
- Avoid trigger foods on an individualized basis (coffee, tea, soda, chocolate, mints, citrus products including tomatoes, alcohol) 1, 2
- Smoking cessation and limiting alcohol consumption are recommended 1, 2
- Avoid vigorous exercise that increases intraabdominal pressure 4, 2
Pharmacologic Treatment
- For patients with typical GERD symptoms, empiric PPI therapy is appropriate initial management without the need for endoscopy 1, 3
- Standard PPI dosing should be taken 30-60 minutes before meals for optimal effect 3
- A 4-8 week trial of single-dose PPI therapy is recommended for initial treatment 3, 5
- After symptom control is achieved, titrate to the lowest effective PPI dose 1, 3
- H2RAs (ranitidine, famotidine) can be used as add-on therapy to PPI, particularly for nighttime symptoms 3
- Antacids and alginates can provide rapid, short-term relief of breakthrough symptoms 6, 7
Treatment Escalation for Persistent Symptoms
- For persistent symptoms despite standard PPI therapy, increase to twice-daily PPI dosing 1, 3
- Consider endoscopy after failed empiric therapy to assess for esophagitis or other pathology 1, 3
- Adding prokinetic therapy to PPI treatment may be considered for patients with persistent symptoms despite optimized PPI therapy 1
- Adding a bedtime H2RA can be considered for patients with refractory GERD, though tachyphylaxis may develop with continued use 3
- Implementing a strict antireflux diet (≤45g fat/day, no coffee, tea, soda, chocolate, mints, citrus products, alcohol) for patients with persistent symptoms 4, 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
- An intensive medical treatment regimen that includes all medical therapeutic options should be instituted before considering antireflux surgery 4
- Address comorbid conditions that may worsen GERD, such as sleep apnea 1
Surgical Options
- Antireflux surgery may be considered for patients with objectively documented GERD that fails maximal medical therapy for at least 3 months 1
- Surgery has improved cough in approximately 85% of patients 6-12 months following surgery in prospective trials when cough has not improved with medical therapy 4
- Surgery should be recommended only in patients with objectively documented gastroesophageal reflux 3
- Patients should be thoroughly evaluated with objective assessments before considering surgical intervention, particularly if they are young and healthy 5
Long-term Management Considerations
- Periodically reassess the need for continued PPI therapy to minimize potential long-term risks 1, 3
- For patients on long-term PPI therapy, objective reflux testing should be offered to confirm the GERD diagnosis 3
- PPI therapy is generally safe for long-term use, though patients should be informed about potential risks and benefits 3, 5
- Reliance on acid suppression alone may potentially place the patient at increased risk of community-acquired pneumonia 4