What is the best medication for gastroesophageal reflux disease (GERD)?

From the Guidelines

Proton pump inhibitors (PPIs) are the most effective medications for gastroesophageal reflux disease (GERD), with a 4- to 8-week trial of single-dose PPI considered safe and appropriate for patients with typical reflux symptoms and no alarm symptoms. According to the 2022 clinical practice update on the personalized approach to the evaluation and management of GERD 1, PPIs are recommended as the first-line treatment for GERD. The study suggests that patients should receive education on GERD pathophysiology and lifestyle modifications, and be involved in a shared decision-making model.

Key Considerations

• A stepwise diagnostic approach should be used to identify mechanisms driving symptoms for a precision management approach
• Patients with typical reflux symptoms and no alarm symptoms can start with a single-dose PPI, with escalation to twice-a-day dosing or switching to a more potent acid suppressive agent if symptoms persist
• Symptom response should prompt PPI titration to the lowest effective dose
• Lifestyle modifications, such as avoiding trigger foods, not eating within 3 hours of bedtime, elevating the head of the bed, maintaining a healthy weight, and quitting smoking, should accompany medication

Treatment Options

• PPIs, such as omeprazole (20-40mg daily) or pantoprazole (40mg daily), are generally considered the most effective medications for acid reflux or GERD
• H2 blockers, such as famotidine (20mg twice daily), can be effective alternatives for milder symptoms
• Antacids, such as Tums or Rolaids, provide quick but temporary relief and are best for occasional symptoms

Monitoring and Follow-up

• Objective reflux testing should be offered to establish a diagnosis of GERD and a long-term management plan when long-term PPI therapy is planned
• Upper GI endoscopy is warranted in PPI non-response, presence of alarm signs/symptoms, isolated extra-esophageal symptoms, or in patients who meet criteria to undergo screening for Barrett’s esophagus
• Prolonged wireless pH monitoring off PPI therapy can be utilized to assess esophageal acid exposure in patients without erosive disease on endoscopy and with physiologic acid exposure.

From the FDA Drug Label

1.7 Treatment of Symptomatic Gastroesophageal Reflux Disease (GERD) Lansoprazole delayed-release capsules are indicated for short-term treatment in adults and pediatric patients 12 to 17 years of age (up to eight weeks) and pediatric patients one to 11 years of age (up to 12 weeks) for the treatment of heartburn and other symptoms associated with GERD [see Clinical Studies ( 14.7)].

In a U. S. multi-center, double-blind, placebo-controlled study of 214 patients with frequent GERD symptoms, but no esophageal erosions by endoscopy, significantly greater relief of heartburn associated with GERD was observed with the administration of lansoprazole 15 mg once daily up to eight weeks than with placebo.

The best medication for Gastroesophageal Reflux Disease (GERD), according to the provided drug label, is lansoprazole.

• The recommended dose is 15 mg once daily for up to eight weeks.
• Lansoprazole 15 mg was superior to ranitidine 150 mg (twice daily) in decreasing the frequency and severity of day and night heartburn associated with GERD.
• No significant additional benefit from lansoprazole 30 mg once daily was observed 2.

From the Research

Treatment Options for Gastroesophageal Reflux Disease (GERD)

• Proton pump inhibitors (PPIs) are considered the most effective therapy for symptom relief, healing, and long-term maintenance of GERD 3, 4.
• The effectiveness of PPIs in the long-term treatment of GERD is similar, but they differ in terms of fast onset and duration of antisecretory action, pH-selectivity, metabolism, interactions with other medicines, and dosage forms 5.
• PPIs such as lansoprazole, omeprazole, pantoprazole, and rabeprazole are available for the treatment of GERD, and the choice of PPI may depend on individual patient factors 4, 5.

Efficacy of PPIs in GERD Treatment

• Studies have shown that PPIs are more effective than H2-receptor antagonists (H2RAs) in healing and symptom relief of GERD 3.
• The healing rates of PPIs are higher than those of H2RAs, especially in severe disease 3.
• PPIs have also been shown to be effective in H2RA-refractory disease, with approximately 80% healing occurring in 8 weeks 3.

Considerations for PPI Use

• While PPIs are effective in the treatment of GERD, their long-term use has been associated with adverse outcomes such as gastrointestinal infections, pneumonia, nutrient deficiencies, fractures, and small intestinal bacterial overgrowth 6.
• Provider awareness and patient education are important for the safe and effective use of PPIs, and efforts to deprescribe PPIs may be necessary in individuals who do not require long-term therapy 6.
• Alternative treatment options, such as vonoprazan (a potassium-competitive acid blocker), may be effective for PPI-resistant reflux esophagitis 7.