What is the best course of action for a patient with persistent dysphagia, acid reflux, and chronic insomnia?

Urgent Endoscopy Referral Required for Red Flag Symptoms

This patient requires urgent upper endoscopy referral within 2 weeks due to the combination of progressive dysphagia (both solids and liquids), unintentional weight loss, and failure of PPI therapy—all alarm features that significantly increase the risk of esophageal malignancy or stricture. 1

Immediate Actions for Dysphagia and Weight Loss

Endoscopy Indication (Highest Priority)

• Upper endoscopy is mandated in patients presenting with dysphagia, weight loss, or persistent symptoms despite PPI therapy 1
• The combination of dysphagia affecting both solids and liquids with 6-month duration and half-stone weight loss over 3 months represents multiple alarm features requiring urgent investigation 1
• Dysphagia occurs in 28% of GERD patients but when progressive and painful, it raises concern for stricture, esophageal adenocarcinoma, or Barrett's esophagus 2
• Complete endoscopic evaluation must include: inspection for erosive esophagitis (Los Angeles classification), Barrett's esophagus (Prague classification with biopsy), strictures, and assessment of hiatal hernia 1

Critical Pitfall to Avoid

• Do not continue empiric PPI therapy without endoscopy in the presence of alarm symptoms 1
• The 14-day lansoprazole trial prescribed is insufficient—this patient needs diagnostic evaluation before further medical management 1
• Failure of over-the-counter lansoprazole and Gaviscon already indicates PPI non-response, which itself is an indication for endoscopy 1

PPI Management Strategy

Appropriate Dosing for Symptomatic Relief

• While awaiting endoscopy, escalate to lansoprazole 30mg twice daily (not once daily for 14 days) given the severity and PPI failure 1
• Single-dose PPI has already failed (patient reports OTC lansoprazole ineffective), so twice-daily dosing is the next step 1
• Ensure PPI is taken 30-60 minutes before meals for optimal acid suppression 3

Post-Endoscopy Management Depends on Findings

• If erosive esophagitis (Los Angeles B or greater) is found: continue long-term PPI at lowest effective dose indefinitely 1, 3
• If Barrett's esophagus is identified: lifelong PPI therapy plus surveillance endoscopy every 3-5 years for non-dysplastic Barrett's 1
• If endoscopy is normal: perform prolonged wireless pH monitoring off PPI (96-hour preferred) to confirm or exclude GERD 1

Insomnia Management Concerns

Zopiclone Prescribing Issues

• The prescribed zopiclone 3.75mg for one week is appropriate for short-term use, but dependence risk increases significantly with regular use beyond 2-4 weeks 4
• In elderly patients (if applicable), zopiclone dose should not exceed 2mg due to 41% increase in drug exposure and prolonged elimination 4
• Zopiclone should not be repeated as correctly stated in the consultation—chronic insomnia requires non-pharmacologic interventions 4

Evidence-Based Insomnia Treatment

• Cognitive behavioral therapy for insomnia (CBT-I) is first-line treatment for chronic insomnia and has superior long-term outcomes compared to hypnotics 1
• The referral to sleepful.org.uk for online CBT-I is appropriate and should be emphasized as the primary intervention 1
• Consider pharmacologic neuromodulation (low-dose mirtazapine, trazodone, or doxepin) if CBT-I fails, though mirtazapine was previously discontinued due to weight gain 1

Face-to-Face Appointment Requirements

Essential Clinical Assessments

• Document current weight and calculate BMI—weight loss of half a stone (approximately 3.2kg) over 3 months needs quantification 1
• Perform abdominal examination to assess for epigastric mass, hepatomegaly, or other concerning findings 1
• Assess for additional alarm features: anemia (check conjunctival pallor), lymphadenopathy (particularly supraclavicular) 1, 5

Referral Pathway and Timeframe

Urgent Two-Week Cancer Pathway

• This patient meets criteria for urgent suspected cancer referral (dysphagia + weight loss) 1
• Endoscopy should be performed within 2 weeks, not as a routine gastroenterology referral 1
• Do not delay referral pending face-to-face appointment—initiate urgent referral immediately 1

Safety-Netting Specific to This Case

Red Flags Requiring Emergency Evaluation

• Worsening dysphagia preventing oral intake (risk of dehydration and aspiration) 1, 5
• New onset of hematemesis, melena, or severe chest pain 1, 5
• Progressive weight loss or inability to maintain nutrition 1, 5
• Development of persistent vomiting (currently absent but concerning if develops) 1, 5

Risk Stratification for Esophageal Adenocarcinoma

This Patient's Risk Profile

• Chronic GERD symptoms for 6 months with nocturnal reflux increases Barrett's esophagus risk 1
• Recent alcohol abstinence (4 weeks) suggests previous regular use—alcohol is a risk factor for esophageal pathology 5
• Weight loss and dysphagia progression are concerning for advanced disease requiring urgent evaluation 1
• The 5-year survival of esophageal adenocarcinoma is poor overall but greatly improved by early detection, making urgent endoscopy critical 1