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

Management of Gastroesophageal Reflux Disease (GERD)

Proton pump inhibitors (PPIs) are the most effective first-line pharmacological treatment for GERD, superior to histamine-2 receptor antagonists (H2RAs) and placebo. 1

Initial Treatment Approach

• For patients with typical GERD symptoms without alarm features, a 4-8 week trial of single-dose PPI therapy is recommended without the need for initial endoscopy 1, 2
• Empirical therapy is appropriate initial management for patients with uncomplicated heartburn 3
• PPIs are more effective than H2RAs, which are more effective than placebo for healing esophagitis and providing symptomatic relief 3, 1
• Standard PPI dosing should be taken 30-60 minutes before meals for optimal effect 2
• After symptom control is achieved, PPI should be tapered to the lowest effective dose 1, 2

Lifestyle Modifications

• Weight loss should be recommended for all overweight or obese patients with GERD 3, 1
• Elevation of the head of the bed (6-8 inches) is recommended for patients with nighttime symptoms or regurgitation when recumbent 3, 1
• Avoid lying down for 2-3 hours after meals to reduce esophageal acid exposure 1, 2
• Individualized dietary modifications based on symptom triggers (e.g., avoiding alcohol, coffee, spicy foods if they consistently trigger symptoms) 3, 1
• Limiting fat intake to less than 45g per day as part of an antireflux diet may be beneficial 1
• Weight loss and head of bed elevation are the only lifestyle interventions with evidence supporting improvement in GERD measures 4

Treatment Escalation for Persistent Symptoms

• If symptoms persist despite standard PPI therapy, increase to twice-daily PPI dosing 3, 1
• Consider adding H2RAs as adjunctive therapy, particularly for nighttime symptoms 1, 2
• Adding prokinetic therapy to PPI treatment may be considered for patients with persistent symptoms 3, 1
• Patients whose heartburn has not adequately responded to twice-daily PPI therapy should be considered treatment failures, making that a reasonable upper limit for empirical therapy 3
• Endoscopy should be performed to assess for erosive disease or alternative diagnoses if symptoms persist despite optimized PPI therapy 1, 2

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
• A comprehensive treatment regimen including antireflux diet, acid suppression therapy with PPIs, and lifestyle modifications should be implemented for patients with extraesophageal symptoms 3, 1
• Metoclopramide is not recommended as monotherapy or adjunctive therapy in patients with esophageal or suspected extraesophageal GERD syndromes 3

Management of Refractory GERD

• 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 despite optimized PPI therapy 3, 1
• Addressing comorbid conditions that may worsen GERD (e.g., sleep apnea) is important 3, 1
• For patients with objectively documented GERD that fails maximal medical therapy for at least 3 months, antireflux surgery may be considered 3, 1
• For functional heartburn (normal acid exposure, negative symptom association), consider neuromodulators (tricyclic antidepressants, selective serotonin reuptake inhibitors) 3, 2

Pitfalls and Caveats

• Endoscopy with biopsy is recommended for patients with an esophageal GERD syndrome with troublesome dysphagia 3
• Normal endoscopy findings do not rule out GERD as the cause of symptoms 3
• Periodically reassess the need for continued PPI therapy to minimize potential long-term risks 1, 2
• Patients with presumed extraesophageal symptoms who fail PPI therapy should be investigated for non-GERD causes before proceeding to endoscopy or function testing 3
• Although there is physiologic evidence that exposure to tobacco, alcohol, chocolate, and high-fat meals decreases lower esophageal sphincter pressure, there is limited published evidence of the efficacy of dietary measures for symptom improvement 4