What is the diagnosis and treatment for Non-Erosive Gastroesophageal Reflux Disease (GERD)?

From the Guidelines

Non-erosive gastroesophageal reflux disease (NERD) should be diagnosed and treated with a stepwise approach, starting with lifestyle modifications and a 4- to 8-week trial of single-dose proton pump inhibitors (PPIs), with escalation to twice-a-day dosing or switching to a more potent acid suppressive agent if symptoms persist, as recommended by the most recent guidelines 1.

Diagnosis

The diagnosis of NERD involves a combination of clinical evaluation, endoscopy, and ambulatory pH monitoring. Patients with typical reflux symptoms, such as heartburn and regurgitation, but without visible esophageal damage during endoscopy, may be diagnosed with NERD.

• A personalized approach to diagnosis and treatment should be taken, based on findings on endoscopy and prolonged ambulatory wireless pH monitoring 1.
• Patients with no GERD likely have an alternate explanation for symptoms, which can be a functional disorder; hence, PPIs can be discontinued, and other management options explored.

Treatment

Treatment of NERD typically begins with lifestyle modifications, including:

• Weight loss if overweight
• Avoiding meals within 3 hours of bedtime
• Elevating the head of the bed
• Avoiding trigger foods like caffeine, chocolate, alcohol, and fatty or spicy foods For medication, start with proton pump inhibitors (PPIs) such as omeprazole 20mg or pantoprazole 40mg once daily, taken 30 minutes before breakfast for 4-8 weeks.
• If symptoms persist, the dose can be increased or split into twice daily 1.
• H2 blockers like famotidine 20mg twice daily can be used as an alternative or add-on therapy.
• Antacids provide quick but temporary relief for breakthrough symptoms.

Further Evaluation

NERD responds to treatment more slowly than erosive GERD because symptoms in NERD may be caused by factors beyond acid exposure, including esophageal hypersensitivity and altered motility.

• If symptoms don't improve after 8 weeks of optimal therapy, further evaluation with pH monitoring or impedance testing may be necessary to confirm the diagnosis and guide treatment 1.
• A precision approach to escalation of management is suggested for patients with ongoing symptoms despite these measures, which should be driven by integrity of the anti-reflux barrier, presence of visceral hypersensitivity and hypervigilance, confirmation of PPI refractory-GERD, symptom profile, body mass index, and esophageal (as well as gastric) motor function 1.

From the FDA Drug Label

1.4 Treatment of Symptomatic Gastroesophageal Reflux Disease (GERD) Omeprazole delayed-release capsules are indicated for the treatment of heartburn and other symptoms associated with GERD for up to 4 weeks in patients 2 years of age and older.

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

The diagnosis of Non-Erosive Gastroesophageal Reflux Disease (GERD) is not explicitly mentioned in the provided drug labels. However, the treatment for Symptomatic Gastroesophageal Reflux Disease (GERD) is indicated as:

• Omeprazole delayed-release capsules for up to 4 weeks in patients 2 years of age and older 2
• Lansoprazole delayed-release capsules 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) 3 Key points:
• The provided drug labels do not explicitly differentiate between erosive and non-erosive GERD.
• The treatment options listed are for symptomatic GERD, which may include non-erosive GERD.
• It is essential to consult the full prescribing information and consider individual patient needs when selecting a treatment option.

From the Research

Diagnosis of Non-Erosive Gastroesophageal Reflux Disease (GERD)

• The diagnosis of Non-Erosive GERD can be made based on symptoms, with acid regurgitation and heartburn being the most specific symptoms for GERD 4.
• In the absence of alarm symptoms, a presumptive diagnosis can be made and empiric therapy initiated 4.
• Further diagnostic testing may be needed to confirm the diagnosis, assess for complications, or rule out alternative causes of symptoms 4, 5.

Treatment of Non-Erosive GERD

• The primary goal of treatment is to relieve symptoms, promote mucosal healing, and prevent relapse and complications 6, 7.
• Lifestyle modifications, such as weight loss, head of bed elevation, and avoidance of trigger foods, can help improve symptoms 7, 4, 5.
• Pharmacologic agents, including antacids, histamine H2-receptor antagonists (H2RAs), and proton pump inhibitors (PPIs), can be used to suppress acid production and relieve symptoms 6, 7, 5, 8.
• PPIs are more effective than H2RAs in healing GERD and relieving symptoms, but may have interactions with other medications and have a slower onset of action 7, 8.
• Treatment should be tailored to the individual patient, with the goal of achieving rapid relief of symptoms and maintaining relief with the minimum effective therapy 5.
• Long-term therapy is often needed to maintain symptom relief and prevent complications 6, 5.