What are the treatment guidelines for gastroesophageal reflux disease (GERD) or heartburn?

Treatment Guidelines for Heartburn (GERD)

Start with a 4-8 week trial of once-daily proton pump inhibitor (PPI) therapy taken 30-60 minutes before breakfast for patients with typical heartburn symptoms—this is the most effective first-line treatment and does not require endoscopy before initiating therapy. 1, 2

Initial Pharmacologic Management

First-Line PPI Therapy

• PPIs are superior to H2-receptor antagonists (H2RAs), which are superior to placebo, for both healing esophagitis and relieving heartburn symptoms 1
• Take PPIs 30-60 minutes before meals (typically breakfast) for optimal acid suppression 2, 3
• Standard once-daily dosing is effective for most patients with uncomplicated heartburn 1, 4
• Common PPIs include omeprazole 20mg daily or lansoprazole 30mg daily 4, 5
• Treatment duration of 4-8 weeks is appropriate for initial symptom control 1, 2

When Symptoms Persist on Standard Therapy

• Increase to twice-daily PPI dosing (before breakfast and dinner) if symptoms persist after 4-8 weeks of once-daily therapy 1, 2
• This represents the reasonable upper limit of empirical therapy before considering endoscopy 1
• Almost all PPI efficacy data comes from once-daily studies, but expert consensus strongly supports twice-daily dosing for refractory symptoms 1

Lifestyle Modifications (Adjunctive to Pharmacotherapy)

Evidence-Based Interventions

• Weight loss for overweight/obese patients improves both pH profiles and symptoms 2, 3, 6
• Elevate the head of the bed 6-8 inches for patients with nighttime heartburn or regurgitation—this improves esophageal acid exposure time 1, 2, 3, 6
• Avoid lying down for 2-3 hours after meals to reduce acid exposure 2, 7, 3

Dietary Modifications (Individualized Based on Triggers)

• Avoid specific foods only if they consistently trigger symptoms in that patient (e.g., alcohol, coffee, spicy foods, chocolate, citrus) 1, 2, 3
• There is no published evidence that tobacco or alcohol cessation improves GERD symptoms or pH profiles, despite physiologic rationale 6
• Lifestyle modifications alone are insufficient for most patients with established GERD and must be combined with acid suppression 7, 3

Management Algorithm for Treatment Failures

After 8 Weeks of Twice-Daily PPI

• Perform endoscopy to assess for erosive esophagitis, Barrett's esophagus, or alternative diagnoses 1, 2, 3
• Patients failing twice-daily PPI therapy should be considered treatment failures 1

For Non-Erosive Disease on Endoscopy

• Consider prolonged wireless pH monitoring off PPI therapy to confirm GERD diagnosis 2, 3
• Evaluate for functional heartburn (normal acid exposure with negative symptom association) 2, 3
• For confirmed functional heartburn, consider neuromodulators such as tricyclic antidepressants or SSRIs rather than escalating acid suppression 2, 3

Additional Options for Confirmed Refractory GERD

• Adding bedtime H2RA to twice-daily PPI may help nighttime symptoms, though tachyphylaxis develops with continued use 2, 7
• Do NOT use metoclopramide as monotherapy or adjunctive therapy—it has an unfavorable risk-benefit profile 1, 7
• Consider laparoscopic fundoplication in experienced centers for objectively documented PPI-refractory GERD 2, 3

Long-Term Management

Maintenance Therapy

• After achieving symptom control, taper PPI to the lowest effective dose 2, 7, 3
• Periodically reassess the need for continued therapy to minimize potential long-term risks 2, 7, 3
• For patients requiring long-term PPI (>12 months), consider objective reflux testing to confirm diagnosis 2
• Controlled studies for maintenance therapy do not extend beyond 12 months 5

PPI Safety Considerations

• Long-term PPI use may increase risk of kidney problems (tubulointerstitial nephritis), Clostridium difficile diarrhea, bone fractures (hip, wrist, spine), and certain types of lupus 4
• Despite these risks, long-term PPI therapy is generally safe and no cases of gastric cancer or endocrine neoplasia have been documented with PPI use 8
• Use the lowest effective dose for the shortest time needed 4

Common Pitfalls to Avoid

• Do not add nocturnal H2RA to twice-daily PPI—there is no evidence this improves efficacy 1
• Do not use higher-than-standard PPI doses—the data supporting this are weak 1
• Do not continue empirical therapy beyond twice-daily PPI without endoscopy 1
• Antacids can be used for breakthrough symptoms but are not sufficient as monotherapy for established GERD 1, 9
• After discontinuation of PPI therapy, almost all patients with esophagitis will relapse within 30 weeks 8