What are the guidelines for managing Gastroesophageal Reflux Disease (GERD)?

GERD Management Guidelines

Initial Assessment and Diagnosis

For patients with typical GERD symptoms (heartburn and acid regurgitation) without alarm features, start empiric PPI therapy for 4-8 weeks without requiring endoscopy. 1, 2

When to Investigate Further

• Perform endoscopy if alarm features are present: bilious vomiting, gastrointestinal bleeding, forceful vomiting, abdominal tenderness, dysphagia, or weight loss 1
• Consider endoscopy after failed empiric PPI therapy to assess for erosive esophagitis or alternative diagnoses 1, 2
• For refractory symptoms despite optimized therapy, perform prolonged wireless pH monitoring off PPI to confirm GERD diagnosis 2

Lifestyle Modifications

Weight loss is the most evidence-based lifestyle intervention and should be recommended for all overweight or obese patients with GERD. 1, 2, 3

Proven Effective Measures

• Elevate the head of bed 6-8 inches for patients with nighttime symptoms or regurgitation when recumbent 1, 2, 3
• Avoid lying down for 2-3 hours after meals to reduce esophageal acid exposure 1, 2, 4
• Limit fat intake to less than 45g per day as part of an antireflux diet 5, 4

Measures with Limited Evidence

• Avoid specific trigger foods (coffee, chocolate, alcohol, spicy foods, citrus, tomatoes) only if they consistently worsen individual symptoms—there is no evidence supporting blanket dietary restrictions 2, 3
• Tobacco and alcohol cessation have not been shown to improve esophageal pH profiles or symptoms in clinical trials, though general health benefits warrant recommendation 3

Pharmacologic Treatment Algorithm

First-Line Therapy

Start with standard-dose PPI once daily, taken 30-60 minutes before meals, for 4-8 weeks. 1, 2, 4

• PPIs are superior to H2-receptor antagonists and antacids for GERD treatment 1, 4
• Proper timing (30-60 minutes before meals) is essential for optimal effect 1, 2, 6
• Antacids may be used concomitantly with PPIs 6

Escalation for Persistent Symptoms

If symptoms persist after 4-8 weeks of standard-dose PPI, increase to twice-daily dosing (before breakfast and dinner). 1, 2, 4

• Adding H2-receptor antagonists at bedtime can help control breakthrough nighttime symptoms 1, 2
• Perform endoscopy at this stage to assess for erosive disease or alternative diagnoses 1, 2

Long-Term Management

After achieving symptom control, taper PPI to the lowest effective dose and periodically reassess the need for continued therapy. 2

• This minimizes potential long-term risks including community-acquired pneumonia, gastroenteritis, and candidemia 1
• Chronic antacid therapy is not recommended due to associated risks 1

Management of Refractory GERD

For confirmed PPI-refractory GERD (symptoms persisting despite twice-daily PPI for at least 3 months), consider adding prokinetic therapy and implementing a strict antireflux diet. 5, 2, 4

Intensive Medical Regimen

• Strict antireflux diet: no coffee, tea, soda, chocolate, mints, citrus products (including tomatoes), or alcohol; no smoking; limit vigorous exercise that increases intraabdominal pressure 5, 4
• Twice-daily PPI at maximum dose 5, 2
• Prokinetic therapy added to PPI treatment 5, 2, 4
• Address comorbid conditions such as obstructive sleep apnea or medications that worsen GERD (nitrates, progesterone, calcium channel blockers) 5, 4

Surgical Intervention

Laparoscopic fundoplication should be reserved for carefully selected patients with objectively documented GERD who have failed at least 3 months of intensive medical therapy. 5, 1, 2

• Surgery shows improvement or cure of symptoms in 85-86% of properly selected patients 4
• Fundoplication is associated with significant morbidity and should only be performed in experienced centers 1
• Before surgery, carefully exclude other etiologies and counsel patients about realistic expectations 1

Special Populations and Considerations

Extraesophageal GERD (Chronic Cough, Laryngitis, Asthma)

Extraesophageal symptoms require more intensive and prolonged therapy: twice-daily PPI for 8-12 weeks plus strict antireflux diet, with response assessment at 1-3 months. 5, 1, 2, 4

• Response rates are lower for extraesophageal symptoms compared to typical GERD symptoms 1, 2
• Consider adding prokinetic therapy if PPI alone is ineffective 5, 4
• Normal esophagoscopy findings do not rule out GERD as the cause of chronic cough 5
• If empiric therapy fails, perform 24-hour esophageal pH monitoring on therapy to determine if treatment needs intensification 5

Pediatric GERD

For infants with GERD, implement a 2-4 week trial of maternal exclusion diet (restricting at least milk and egg) for breastfed infants or extensively hydrolyzed protein formula for formula-fed infants. 5, 1, 2

Infants (Under 12 Months)

• Thickened feedings (up to 1 tablespoon rice cereal per ounce of formula) and smaller, more frequent feedings can reduce symptoms 5, 1, 2
• Avoid thickened feedings in preterm infants due to association with necrotizing enterocolitis 5
• PPI therapy should not be used for uncomplicated physiologic reflux in infants 2

Children 1-11 Years

• Weight ≤30 kg: 15 mg lansoprazole once daily for up to 12 weeks 6
• Weight >30 kg: 30 mg lansoprazole once daily for up to 12 weeks 6
• PPIs should only be used for confirmed GERD, not physiologic GER 1, 2

Adolescents 12-17 Years

• Non-erosive GERD: 15 mg lansoprazole once daily for up to 8 weeks 6
• Erosive esophagitis: 30 mg lansoprazole once daily for up to 8 weeks 6

Hepatic Impairment

• Reduce dose to 15 mg daily in patients with severe liver impairment (Child-Pugh C) 6

Common Pitfalls and Caveats

Medications to Avoid

• Do not use metoclopramide as monotherapy or adjunctive therapy for GERD due to unfavorable risk-benefit profile (adverse effects include drowsiness, restlessness, and extrapyramidal reactions) 1, 2, 4
• H2-antagonists can cause tachyphylaxis within 6 weeks and may increase risk of liver disease and gynecomastia 1

Important Considerations

• Take lansoprazole at least 30 minutes prior to sucralfate to avoid drug interactions 6
• For missed PPI doses, take as soon as possible unless the next scheduled dose is due; never double up 6
• Lifestyle modifications alone are insufficient for most patients with established GERD and should be used as adjuncts to pharmacologic therapy 2
• Upper endoscopy with esophageal biopsy may be needed to exclude eosinophilic esophagitis, which can mimic GERD 5