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

Treatment of 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, 2

Initial Treatment Approach

Pharmacologic Therapy

• For patients with typical GERD symptoms, empiric PPI therapy is appropriate initial management without the need for endoscopy 1, 2
• Standard PPI dosing should be taken 30-60 minutes before meals for optimal effect 2
• A 4-8 week trial of single-dose PPI therapy is recommended for initial treatment 3
• PPIs are FDA-approved for the treatment of heartburn and other symptoms associated with GERD for up to 4 weeks 4, 5
• H2RAs (ranitidine, famotidine) are less effective than PPIs but more effective than placebo 6
• Antacids can provide rapid, short-term relief of breakthrough symptoms 3

Lifestyle Modifications

• Weight loss should be recommended for all overweight or obese patients with GERD 1, 2
• Elevation of the head of the bed (6-8 inches) is recommended 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, 3
• Implement an antireflux diet that includes limiting fat intake to less than 45g per day 2
• Avoid trigger foods on an individualized basis (e.g., coffee, chocolate, alcohol, spicy foods, citrus, tomatoes) if they consistently trigger symptoms 1, 2

Treatment Escalation for Persistent Symptoms

• For persistent symptoms despite standard PPI therapy, increase to twice-daily PPI dosing 1, 2
• 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, 3
• Metoclopramide is not recommended as monotherapy or adjunctive therapy due to unfavorable risk-benefit profile 6
• Adding bedtime H2RA to PPI therapy may help with nighttime symptoms, though tachyphylaxis may develop with continued use 3

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) 2
• Response rates to PPI therapy are lower for extraesophageal symptoms compared to typical GERD symptoms 2
• For patients with cough due to GERD, an intensive medical treatment regimen should include: antireflux diet, acid suppression with a PPI, prokinetic therapy, and addressing comorbid conditions 6

Management of Refractory GERD

• If symptoms persist despite optimized PPI therapy, endoscopy should be performed to assess for erosive disease or alternative diagnoses 3
• Implementing a strict antireflux diet (≤45g fat/day, no coffee, tea, soda, chocolate, mints, citrus products, alcohol) may be considered 1
• Address comorbid conditions that may worsen GERD, such as sleep apnea 1
• Antireflux surgery may be considered for patients with objectively documented GERD that fails maximal medical therapy for at least 3 months 2, 3
• 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 2

Long-term Management Considerations

• After initial symptom control, titrate to the lowest effective PPI dose 1
• 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, 7

Common Pitfalls and Caveats

• Patients requiring an intensive medical treatment regimen should be treated with a comprehensive approach rather than acid suppression alone 6
• Reliance on acid suppression alone may potentially place the patient at increased risk of community-acquired pneumonia 2
• Normal endoscopy findings do not rule out GERD as the cause of symptoms 6
• For patients with chronic cough due to GERD, treatment should be assessed within 1-3 months 6
• Patients with warning symptoms (dysphagia, weight loss, bleeding) should undergo endoscopy rather than empiric therapy 7