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 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, 3
- 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 worsen 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, 6
- 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, 6
- After initial symptom control, titrate to the lowest effective PPI dose 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) 2, 6
- 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, and prokinetic therapy 6
- Addressing comorbid conditions that may worsen GERD (e.g., sleep apnea) is important for optimal management 1, 6
Surgical Options
- Antireflux surgery may be considered for patients with objectively documented GERD that fails maximal medical therapy for at least 3 months 1, 2
- 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
- Laparoscopic fundoplication is an invasive treatment alternative in select patients after thorough and objective assessments, particularly if they are young and healthy 7
Common Pitfalls and Caveats
- Metoclopramide should not be used as monotherapy or adjunctive therapy for GERD due to unfavorable risk-benefit profile 1, 6
- Normal esophagoscopy findings do not rule out GERD as the cause of symptoms, especially in patients with extraesophageal manifestations 6
- Periodically reassess the need for continued PPI therapy to minimize potential long-term risks 1, 3
- Reliance on acid suppression alone may potentially place the patient at increased risk of community-acquired pneumonia 2
- For patients on long-term PPI therapy, objective reflux testing should be offered to confirm the GERD diagnosis 3