What is the treatment for gastroesophageal reflux disease (GERD)?

Treatment of Gastroesophageal Reflux Disease (GERD)

Proton pump inhibitors (PPIs) are the first-line and most effective pharmacological treatment for GERD, with once-daily dosing (e.g., omeprazole 20 mg) recommended initially, escalating to twice-daily if symptoms persist. 1, 2, 3

Initial Management Approach

Empiric PPI Therapy

• Start with once-daily PPI therapy (omeprazole 20 mg or equivalent) taken 30 minutes before the first meal of the day for 4-8 weeks in patients with typical GERD symptoms (heartburn, regurgitation). 1, 4, 2
• Endoscopy is not required before initiating treatment in patients without alarm symptoms (dysphagia, weight loss, bleeding, anemia). 5, 3
• PPIs are superior to H2-receptor antagonists (H2RAs) and antacids for both symptom control and healing of erosive esophagitis. 1, 6

Lifestyle Modifications (Concurrent with Medical Therapy)

• Recommend weight loss for all overweight or obese patients, as this directly improves esophageal acid exposure. 1, 7
• Elevate the head of the bed by 6-8 inches for patients with nighttime symptoms or regurgitation. 1, 7
• Avoid lying down for 2-3 hours after meals to reduce esophageal acid exposure. 1, 4
• Identify and avoid individual trigger foods (coffee, chocolate, alcohol, spicy foods, citrus, tomatoes, high-fat foods >45g/day). 4
• Smoking cessation and alcohol limitation are essential. 4, 3

Treatment Escalation for Inadequate Response

Step 1: Optimize PPI Therapy

• Increase to twice-daily PPI dosing (taken 30 minutes before breakfast and dinner) if symptoms persist after 4-8 weeks of once-daily therapy. 5, 4
• Verify proper timing: PPIs must be taken 30 minutes before meals for optimal efficacy. 4
• Consider switching to a different PPI if partial response occurs. 4

Step 2: Add Personalized Adjunctive Therapy

Tailor adjunctive medications to the specific symptom pattern rather than empiric use: 5, 4

• Alginate-containing antacids for breakthrough symptoms and post-prandial symptoms, particularly in patients with hiatal hernia. 5, 4
• H2RAs at bedtime for nocturnal breakthrough symptoms (note: tachyphylaxis limits long-term effectiveness). 5, 4
• Baclofen (GABA-B agonist) for regurgitation-predominant or belch-predominant symptoms (limited by CNS and GI side effects). 5, 6
• Prokinetics only for patients with documented coexistent gastroparesis (metoclopramide is not recommended as monotherapy for GERD due to unfavorable risk-benefit profile). 5, 1

Step 3: Diagnostic Evaluation for Refractory Symptoms

Perform diagnostic testing when symptoms persist despite optimized twice-daily PPI therapy and adjunctive medications: 5

• Upper endoscopy to assess for erosive esophagitis (Los Angeles classification), Barrett's esophagus (Prague classification), hiatal hernia (Hill grade), strictures, or alternative diagnoses. 5, 3
• High-resolution esophageal manometry to exclude achalasia and assess peristaltic function before considering surgical intervention. 5
• 24-hour pH-impedance monitoring on PPI therapy to confirm PPI-refractory GERD versus alternative diagnoses (reflux hypersensitivity, functional heartburn, rumination syndrome, belching disorders). 5
• 96-hour wireless pH monitoring off PPI therapy (if available) for patients without erosive disease to confirm and phenotype GERD. 5

Maintenance Therapy

Long-Term PPI Management

• Continue daily PPI therapy indefinitely for patients with healed erosive esophagitis (Los Angeles B or greater), as discontinuation results in high recurrence rates. 5, 3
• Titrate to the lowest effective dose that maintains symptom control and mucosal healing. 5, 1
• Less-than-daily dosing is not recommended for patients with a history of erosive esophagitis. 5
• On-demand therapy is acceptable only for patients with non-erosive GERD where symptom control is the primary objective. 5
• Periodically reassess the need for continued therapy to minimize potential long-term risks. 1

Special Populations and Scenarios

Extraesophageal GERD Symptoms (Chronic Cough, Laryngitis, Asthma)

• Twice-daily PPI therapy for 8-12 weeks minimum is required, as response rates are lower than for typical symptoms. 5, 1, 4
• Empiric PPI therapy is not recommended for isolated extraesophageal symptoms without concomitant typical esophageal symptoms. 5
• Perform objective reflux testing off medication (pH monitoring) before initiating treatment in patients with isolated extraesophageal symptoms. 5

Reflux Chest Pain Syndrome

• Twice-daily PPI therapy for 4 weeks as an empirical trial after cardiac etiology has been thoroughly excluded. 5
• If chest pain persists, proceed to esophageal manometry and pH monitoring to exclude motility disorders or confirm refractory reflux. 5

Neuromodulation and Behavioral Interventions

• Consider pharmacologic neuromodulation (low-dose antidepressants) and/or referral for cognitive behavioral therapy, esophageal-directed hypnotherapy, or diaphragmatic breathing in patients with functional heartburn, reflux hypersensitivity, or esophageal hypervigilance. 5

Surgical and Endoscopic Interventions

Indications for Anti-Reflux Surgery

Surgery should be considered in carefully selected patients after objective confirmation of GERD: 5

• Patients responsive to but intolerant of PPI therapy (Grade A recommendation). 5
• Patients with persistent troublesome symptoms (especially regurgitation) despite optimized PPI therapy, after weighing risks of new post-surgical symptoms (dysphagia, flatulence, inability to belch, bowel symptoms). 5
• Surgery is NOT recommended for patients well-controlled on medical therapy or as cancer prevention in Barrett's esophagus. 5

Surgical Options

• Laparoscopic fundoplication (partial fundoplication preferred in patients with esophageal hypomotility or impaired peristaltic reserve to reduce dysphagia risk). 5
• Magnetic sphincter augmentation, often combined with crural repair for hiatal hernia. 5
• Transoral incisionless fundoplication (endoscopic option) for carefully selected patients without hiatal hernia. 5
• Roux-en-Y gastric bypass is effective for obese patients with GERD and serves as a salvage option in non-obese patients; sleeve gastrectomy may worsen GERD. 5

Pre-Surgical Requirements

Before any anti-reflux procedure, confirm: 5

• Objective evidence of pathologic GERD (endoscopy showing erosive esophagitis or pH monitoring demonstrating excessive acid exposure off PPI)
• Exclusion of achalasia via high-resolution manometry
• Preserved peristaltic function (some peristalsis must be present)

Common Pitfalls to Avoid

• Do not perform endoscopy routinely to monitor for cancer development in chronic GERD patients, as this has not been shown to reduce cancer mortality. 5
• Do not use metoclopramide as monotherapy or adjunctive therapy for GERD due to unfavorable risk-benefit profile. 1
• Do not recommend anti-reflux surgery for patients well-controlled on medical therapy, as PPI therapy has superior safety. 5
• Do not assume PPI failure equals GERD; consider alternative diagnoses (functional heartburn, achalasia, esophageal spasm) via diagnostic testing. 5
• Do not use less-than-daily PPI dosing for maintenance in patients with previously healed erosive esophagitis. 5