From the Guidelines
For patients with Non-Erosive Gastroesophageal Reflux Disease (NERD), a stepwise diagnostic approach and personalized management plan, including lifestyle modifications and a 4- to 8-week trial of single-dose proton pump inhibitors (PPIs), is recommended. This approach is based on the most recent and highest quality study, which suggests that patients with typical reflux symptoms and no alarm symptoms can be safely treated with a single-dose PPI, with escalation to twice-a-day dosing or switching to a more potent acid suppressive agent if symptoms persist 1.
Diagnosis and Treatment Approach
The diagnosis of NERD involves a combination of clinical evaluation, lifestyle modifications, and pharmacotherapy. Patients should receive education on GERD pathophysiology and lifestyle modifications, and be involved in a shared decision-making model. Lifestyle modifications include:
- Weight loss if overweight
- Avoiding meals within 3 hours of bedtime
- Elevating the head of the bed by 6-8 inches
- Avoiding trigger foods (spicy, fatty, acidic foods, chocolate, caffeine, and alcohol)
Medication Management
For medication management, the following approach is recommended:
- Start with proton pump inhibitors (PPIs) like omeprazole 20mg or pantoprazole 40mg once daily before breakfast for 4-8 weeks
- If symptoms persist, consider twice-daily PPI dosing
- H2-receptor antagonists like famotidine 20mg twice daily can be used for breakthrough symptoms or as maintenance therapy after PPI treatment
- Antacids provide quick but temporary relief for occasional symptoms
Further Evaluation
If symptoms don't improve after 8 weeks of optimal therapy, further evaluation with endoscopy, pH monitoring, or manometry may be needed to assess esophageal acid exposure and rule out other conditions 1. In the absence of confirmed erosive disease or Barrett’s esophagus on endoscopy, prolonged wireless pH monitoring off PPI therapy is utilized to assess esophageal acid exposure. Patients without erosive disease on endoscopy and with physiologic acid exposure often have a functional esophageal disorder, and may benefit from neuromodulation or behavioral interventions.
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)].
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.
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 mentioned, which may be relevant.
- The treatment for Symptomatic GERD with lansoprazole is short-term treatment for up to eight weeks in adults and pediatric patients 12 to 17 years of age, and up to 12 weeks in pediatric patients one to 11 years of age 2.
- The treatment for Symptomatic GERD with omeprazole is for up to 4 weeks in patients 2 years of age and older 3. Since Non-Erosive GERD is not explicitly addressed, no conclusion can be drawn regarding its specific diagnosis and treatment.
From the Research
Diagnosis of Non-Erosive Gastroesophageal Reflux Disease (GERD)
- The diagnosis of Non-Erosive GERD can be established through a symptomatic response to an empiric trial of high-dose proton pump inhibitor (PPI) therapy 4
- A well-taken history can be sufficient to confirm the diagnosis and begin therapy 5
- 24-hour pH monitoring can be used to divide patients with Non-Erosive GERD into three groups: those with abnormal acid exposure time, those with normal acid exposure time but significant correlation between symptoms and reflux events, and those with normal pH study parameters 5
- The proton pump-inhibitor (PPI) test is a sensitive tool for the diagnosis of Non-Erosive GERD 5
Treatment of Non-Erosive Gastroesophageal Reflux Disease (GERD)
- The primary treatment goals for Non-Erosive GERD are relief of symptoms, prevention of symptom relapse, and improvement of quality of life 6, 7, 8
- Proton pump inhibitors (PPIs) are the most effective agents for the treatment of Non-Erosive GERD, although they may be less effective in providing symptom relief compared to patients with erosive esophagitis 4, 5
- Lifestyle modifications, such as elevating the head of the bed and modifying the size and composition of meals, can be used in conjunction with pharmacologic agents to treat Non-Erosive GERD 6, 7
- "On demand" PPI therapy has been considered as a cost-effective strategy for the long-term treatment of Non-Erosive GERD 5
- Laparoscopic antireflux surgery is an effective therapy for selected patients with Non-Erosive GERD, with better outcomes when performed in high-volume centers 4