Initial Treatment for Uncomplicated GERD
Uncomplicated reflux should be treated with empiric proton pump inhibitor (PPI) therapy as first-line treatment, starting with once-daily dosing 30-60 minutes before food, without requiring initial diagnostic testing. 1, 2
First-Line Pharmacological Management
PPIs are the most effective medical treatment for uncomplicated GERD, superior to H2-receptor antagonists (H2RAs), which are in turn more effective than placebo for both healing esophagitis and providing symptomatic relief 1
Start with standard once-daily PPI dosing (e.g., omeprazole 20 mg or lansoprazole 30 mg) taken 30-60 minutes before food for optimal effect 2, 3, 4
For patients with typical heartburn symptoms and no alarm features (dysphagia, bleeding, anemia, weight loss, recurrent vomiting), empiric therapy is appropriate without initial endoscopy 1, 2
Dose Escalation Strategy
If symptoms persist after 4-8 weeks of once-daily PPI therapy, increase to twice-daily dosing 1, 2
Patients whose heartburn has not adequately responded to twice-daily PPI therapy should be considered treatment failures, making this a reasonable upper limit for empirical therapy before pursuing diagnostic testing 1
Do not add a nocturnal H2RA to twice-daily PPI therapy, as there is no evidence of improved efficacy with this approach 1
Lifestyle Modifications
Targeted lifestyle modifications should be recommended based on specific patient history 1:
Elevation of the head of the bed for patients with nighttime heartburn or regurgitation that disturbs sleep 1
Avoidance of specific trigger foods (alcohol, coffee, spicy foods) in patients who consistently experience heartburn after ingestion 1
Weight loss for overweight or obese patients, as this has the strongest evidence for efficacy among lifestyle interventions 1, 4, 5
Avoiding recumbency for 2-3 hours after meals 2
Medications to Avoid
- Do not use metoclopramide as monotherapy or adjunctive therapy for GERD, as it is ineffective and has potential adverse effects 1, 2
When to Pursue Diagnostic Testing
Consider endoscopy or reflux testing if 1, 2:
- No response to twice-daily PPI therapy after 8 weeks
- Alarm symptoms are present (dysphagia, bleeding, anemia, weight loss, recurrent vomiting)
- Atypical or extraesophageal symptoms without typical GERD symptoms
Important Caveats
Nonresponse to PPI should raise suspicion that the diagnosis is not GERD and warrants further investigation 6
Once symptoms are controlled, attempt to withdraw or reduce acid suppression therapy to the minimum dose that controls symptoms 4
The efficacy data for PPIs primarily comes from once-daily dosing studies, though twice-daily dosing is recommended by expert consensus for inadequate responders 1