First-Line Treatment for GERD
Start with once-daily proton pump inhibitor (PPI) therapy, such as omeprazole 20 mg daily or lansoprazole 30 mg daily, as the first-line treatment for GERD. 1, 2, 3, 4
Initial Pharmacological Management
PPIs are the most effective first-line pharmacological treatment for GERD, superior to histamine-2 receptor antagonists (H2RAs), antacids, and placebo for healing esophagitis and providing symptomatic relief. 1, 2, 5
For patients with typical GERD symptoms (heartburn and acid regurgitation), empiric PPI therapy is appropriate without the need for initial endoscopy. 2, 6
Standard dosing includes omeprazole 20 mg once daily or lansoprazole 30 mg once daily, taken before the first meal of the day. 1, 3, 4
Most patients with uncomplicated GERD will respond within 4-8 weeks of once-daily PPI therapy. 1, 3
Lifestyle Modifications as Adjunctive Therapy
While PPIs are the pharmacological cornerstone, targeted lifestyle modifications should be implemented concurrently:
Elevate the head of the bed by 6-8 inches for patients with nighttime symptoms or regurgitation when recumbent. 1, 2
Avoid lying down for 2-3 hours after meals to reduce esophageal acid exposure. 1, 2
Weight loss should be recommended for all overweight or obese patients with GERD. 2
Avoid trigger foods on an individualized basis (coffee, chocolate, alcohol, spicy foods, citrus, tomatoes). 2
Important Considerations
P-CABs (potassium-competitive acid blockers like vonoprazan) should generally NOT be used as first-line therapy for uninvestigated heartburn or nonerosive GERD due to higher costs, less availability, and less robust long-term safety data compared to PPIs. 7
For patients with documented erosive esophagitis, acid suppression with PPIs is essential, as lifestyle modifications alone are insufficient. 2
The duration of initial therapy is typically 4-8 weeks for symptomatic GERD and erosive esophagitis. 1, 3, 4
Treatment Escalation if Symptoms Persist
If symptoms persist after 4-8 weeks of once-daily PPI therapy, increase to twice-daily dosing (e.g., omeprazole 20 mg before breakfast and dinner). 1, 2
Consider endoscopy after failed empiric therapy to assess for esophagitis, Barrett's esophagus, or other pathology. 2, 6
After achieving symptom control, taper to the lowest effective PPI dose to minimize potential long-term risks. 1, 2