What is the best course of action for a 75-year-old patient experiencing belching and a sensation of something being stuck in the throat while on omeprazole (proton pump inhibitor) 20mg?

Management of Belching and Globus Sensation in a 75-Year-Old on Omeprazole 20mg

This patient requires optimization of their current PPI therapy by increasing omeprazole to 40mg twice daily (taken 30-60 minutes before meals) for 8-12 weeks, combined with intensive lifestyle modifications including dietary restrictions and head-of-bed elevation. 1

Initial Assessment and Optimization

The current dose of omeprazole 20mg once daily is insufficient for refractory GERD symptoms. The evidence-based approach requires:

• Increase omeprazole to 40mg twice daily taken 30-60 minutes before meals for optimal acid suppression 2, 1
• Continue this higher dose for a minimum of 8-12 weeks before reassessing, as some patients require months before symptom improvement begins 2, 1
• Ensure proper timing of medication administration, as this is a common reason for treatment failure 1

Intensive Lifestyle and Dietary Modifications

These must be implemented concurrently with medication optimization:

• Strict antireflux diet: limit fat intake to no more than 45g per 24 hours, eliminate coffee, tea, soda, chocolate, mints, citrus products (including tomatoes), and alcohol 2
• Head-of-bed elevation and avoid tight-fitting clothing 2, 1
• Smoking cessation if applicable 2
• Avoid vigorous exercise that increases intra-abdominal pressure 2

Add Prokinetic Therapy

If symptoms persist after 4-8 weeks of optimized PPI therapy:

• Add metoclopramide 10mg three times daily to address potential delayed gastric emptying that may contribute to reflux 2
• Prokinetic therapy combined with high-dose PPI has been shown to improve cough in patients who failed PPI monotherapy 2

Critical Medication Review

Review and eliminate medications that may worsen reflux:

• Bisphosphonates, nitrates, calcium channel blockers, theophylline, and progesterones should be discontinued or substituted if possible 2

Important Caveat About PPI Solubility

Omeprazole absorption can be affected by gastric pH changes. 2 If the patient is taking antacids or H2-receptor antagonists concurrently, these should be separated from omeprazole dosing or discontinued entirely to avoid interference with PPI absorption 2

Timeline and Expectations

• Some patients require up to 179 days (approximately 6 months) for complete cough resolution with medical therapy 2
• The globus sensation and belching may represent extraesophageal manifestations of GERD, which typically require longer treatment courses than typical heartburn 1
• Medical therapy has improved cough in 70-100% of patients in prospective trials when not limited to acid suppression alone 2

When to Consider Further Evaluation

If symptoms persist after 8-12 weeks of optimized therapy (high-dose PPI twice daily + prokinetics + lifestyle modifications):

• 24-hour pH monitoring (preferably off medication) to confirm GERD diagnosis and assess for non-acid reflux 1
• Upper endoscopy to evaluate for erosive esophagitis, Barrett's esophagus, or alternative diagnoses 1
• Consider evaluation for eosinophilic esophagitis or other structural abnormalities that may cause globus sensation 2

Alternative Considerations if Medical Therapy Fails

After exhausting intensive medical therapy:

• Antireflux surgery (fundoplication) has shown 86% improvement in chronic cough symptoms in patients who failed maximal medical therapy 2, 1
• Surgery should only be considered after documented reflux on pH monitoring and failure of comprehensive medical management including diet, high-dose PPI, and prokinetics 2

Common Pitfall to Avoid

Do not assume PPI failure means the diagnosis is wrong. 2, 3 Omeprazole reduces acid content but does not reduce the total number of reflux episodes—it converts acid reflux to weakly acidic or non-acid reflux 3. This explains why symptoms may persist despite PPI therapy, and why adding prokinetics (which reduce reflux episodes themselves) is critical 2

The long-term use of PPIs carries cardiovascular risks, but in a 75-year-old with refractory symptoms, the benefit of symptom control outweighs these risks during the 8-12 week therapeutic trial 2