How to manage recurrent GORD symptoms in a patient with a history of GORD and family history of cardiovascular disease?

Management of Recurrent Gastro-Oesophageal Reflux Disease (GORD)

For this patient with recurrent GORD symptoms, the most appropriate management is to optimize PPI therapy by increasing to twice daily dosing, implementing comprehensive lifestyle modifications, and considering adjunctive therapy for nocturnal symptoms.

Optimizing PPI Therapy

• Increase PPI therapy to twice daily dosing since the patient has had only partial response to previous treatment and symptoms have recurred after stopping medication 1
• Consider switching to a more effective acid suppressive agent if symptoms persist despite dose increase 1
• Omeprazole 20mg twice daily before meals is an appropriate choice for treatment of symptomatic GORD 2
• PPIs should be taken 30-60 minutes before meals for optimal effect 3
• Treatment duration of 4-8 weeks is recommended for the acute phase, followed by maintenance therapy at the lowest effective dose 1

Adjunctive Therapy Options

• Add H2-receptor antagonists (like famotidine) specifically for nocturnal symptoms, as the patient reports symptoms at 2-3am 1, 3
• Continue alginate antacids (Acidex) for breakthrough symptoms as they form a physical barrier and provide rapid relief 1
• Consider repeating H. pylori testing before starting treatment as recommended, since previous test was negative but symptoms have recurred 1

Lifestyle Modifications

• Implement dietary modifications including limiting fat intake and avoiding trigger foods such as chocolate, mints, citrus products, and tomatoes 3
• Recommend weight management if the patient is overweight 1
• Elevate the head of the bed for nocturnal symptoms 3
• Address irregular meal times, which can exacerbate GORD symptoms 1
• Consider stress management techniques given the recent family stress (brother-in-law's death) which may be contributing to symptom exacerbation 1

Monitoring and Follow-up

• Reassess response after 4-8 weeks of optimized therapy 1
• If symptoms persist despite optimized medical therapy, consider referral for endoscopy and prolonged wireless pH monitoring to confirm diagnosis 1
• The ECG that has been arranged is appropriate given the chest discomfort and family history of cardiovascular disease to rule out cardiac causes 1

Important Considerations

• The patient's chest discomfort is likely related to GORD but cardiac causes should be excluded given the family history of sudden cardiac death 1
• Long-term PPI therapy is generally safe but should be maintained at the lowest effective dose 1, 4
• If symptoms persist despite optimized therapy for 12 months, objective reflux testing should be offered to confirm the diagnosis and guide long-term management 1
• H2-receptor antagonists may develop tolerance within 6 weeks of continuous use, potentially limiting their long-term effectiveness 3

If Symptoms Persist

• Consider behavioral interventions and neuromodulation if functional components are suspected 1
• For severe refractory GORD with objective evidence of pathologic reflux, surgical options like laparoscopic fundoplication may be considered 1