What should I do next to manage my GERD symptoms, which include a throat lump sensation after eating, despite taking Vono (Esomeprazole) 20 and Ganaton (Itopride) OD 150 for 30 days?

Management of Persistent GERD Symptoms Despite Current Therapy

You need to escalate your PPI therapy to twice-daily dosing (Esomeprazole 20 mg twice daily) and continue the Itopride, as your symptoms after 30 days indicate inadequate acid suppression despite single-dose PPI and prokinetic therapy. 1

Why Your Current Treatment Is Insufficient

Your throat lump sensation (globus), post-meal regurgitation with food smell, and burping are classic signs of inadequate GERD control. After 4-8 weeks of single-dose PPI therapy without adequate response, guidelines explicitly recommend escalating to twice-daily PPI dosing rather than continuing the same regimen. 1

Immediate Next Steps

Step 1: Optimize Your Acid Suppression

• Increase Esomeprazole to 20 mg twice daily (morning and evening, 30-60 minutes before meals) for the next 4-8 weeks 1
• Continue your Itopride 150 mg daily, as adding prokinetics to PPIs has been shown to significantly improve GERD symptoms, particularly regurgitation and throat symptoms, in patients who don't respond to PPI monotherapy 2, 3, 4
• The combination of PPI plus Itopride is more effective than PPI alone for your specific symptoms (throat lump, regurgitation, postprandial fullness) 2, 4

Step 2: Add Alginate Antacids for Breakthrough Symptoms

• Take alginate-based antacids (like Gaviscon) after meals and at bedtime to neutralize the postprandial acid pocket that's causing your throat symptoms 1
• This is particularly helpful for the post-meal throat lump sensation you're experiencing 1

Step 3: Aggressive Lifestyle Modifications

• Avoid bread and other refined carbohydrates that are clearly triggering your symptoms 1
• Elevate the head of your bed by 6-8 inches 1
• If you're overweight, weight loss is critical—even a 3.5-point BMI reduction significantly improves GERD symptoms 1
• Avoid eating within 3 hours of bedtime 1

What Happens If This Doesn't Work

After 4-8 Weeks on Twice-Daily PPI + Itopride:

If symptoms persist or only partially improve, you need objective testing to confirm GERD and guide further treatment:

1. Upper endoscopy to look for erosive esophagitis, hiatal hernia, or Barrett's esophagus 1
2. 96-hour wireless pH monitoring OFF PPI (if endoscopy is normal) to confirm acid exposure and phenotype your GERD 1

This testing is critical because continuing PPI therapy beyond 12 months without proven GERD requires objective confirmation that you actually have acid-related disease. 1

Important Considerations About Your Throat Symptoms

Your throat lump sensation (globus) that improves with talking or walking suggests a component of esophageal hypervigilance or reflux hypersensitivity. 1 If objective testing shows normal acid exposure despite your symptoms, you may have functional heartburn rather than true GERD, which would require:

• Low-dose neuromodulators (tricyclic antidepressants) 1
• Cognitive behavioral therapy or hypnotherapy 1
• Diaphragmatic breathing exercises 1

Common Pitfalls to Avoid

• Don't continue single-dose PPI indefinitely without escalation—this is inadequate therapy for your symptom severity 1
• Don't assume all throat symptoms are GERD—if symptoms persist after optimized therapy, investigate non-GERD causes (ENT evaluation) 1
• Don't stop the Itopride—the combination therapy is more effective than PPI alone for regurgitation and throat symptoms 2, 3, 4
• Don't delay objective testing beyond 12 months if you're still on PPI therapy without proven GERD 1

Timeline Expectations

• 2-4 weeks: You should notice improvement in heartburn and regurgitation 2
• 4-8 weeks: Throat symptoms and globus sensation should significantly improve 2, 4
• If no improvement by 8 weeks: Proceed to endoscopy and pH monitoring 1

The key is that GERD response to therapy is more variable than other conditions—some patients respond within 2 weeks, others take several months, particularly for extra-esophageal symptoms like throat lump. 1 However, you should see some improvement by 4-8 weeks on optimized therapy.