What are the treatment options for acid reflux?

Treatment of Acid Reflux (GERD)

Start with a proton pump inhibitor (PPI) taken once daily, 30-60 minutes before the first meal of the day, for 4-8 weeks—this is the most effective first-line treatment and superior to all other pharmacological options. 1, 2

First-Line Pharmacological Treatment

• PPIs are the cornerstone of GERD therapy and should be initiated empirically for typical symptoms (heartburn, regurgitation) without requiring endoscopy first 1, 2
• Any commercially available PPI (omeprazole, esomeprazole, lansoprazole, etc.) is appropriate initially—they are FDA-approved for treating symptomatic GERD and erosive esophagitis 3
• Critical timing: Take the PPI 30-60 minutes before meals for optimal acid suppression, not at bedtime or with food 1, 2, 4
• PPIs are superior to H2-receptor antagonists (H2RAs) and placebo for both symptom relief and healing erosive esophagitis 1, 2

Essential Lifestyle Modifications

Implement these evidence-based changes alongside PPI therapy:

• Weight loss for all overweight or obese patients—this has the strongest evidence of any lifestyle intervention 1, 2, 5
• Elevate the head of the bed by 6-8 inches for nighttime symptoms or regurgitation when lying down 1, 2, 5
• Avoid lying down for 2-3 hours after meals to reduce esophageal acid exposure 1, 2, 5
• Smoking cessation and limiting alcohol consumption—both worsen GERD symptoms 1, 5
• Identify and avoid individual dietary triggers (coffee, chocolate, citrus, tomatoes, spicy foods, carbonated beverages) on a personalized basis 1, 5

Treatment Escalation for Persistent Symptoms

If symptoms continue after 4-8 weeks of standard-dose PPI:

• Increase to twice-daily PPI dosing (before breakfast and before dinner) for more complete acid suppression 1, 2
• Verify proper PPI timing and adherence before concluding treatment failure—many patients take PPIs incorrectly 2
• Consider endoscopy after failed empiric therapy to assess for esophagitis, Barrett's esophagus, or other pathology 1
• For breakthrough nighttime symptoms, add an H2RA at bedtime, though tolerance may develop with continued use 2

Refractory GERD Management

For patients not responding to twice-daily PPI:

• Implement a strict antireflux diet: limit fat to ≤45g per day, eliminate coffee, tea, soda, chocolate, mints, citrus products, and alcohol 1, 2
• Consider adding prokinetic therapy to PPI treatment, though metoclopramide should be avoided due to unfavorable risk-benefit profile 1
• Address comorbid conditions that worsen GERD, such as sleep apnea 1
• Perform endoscopy and pH monitoring off PPI therapy to objectively confirm GERD diagnosis before further escalation 2
• Antireflux surgery may be considered for objectively documented GERD that fails maximal medical therapy for at least 3 months 1

Special Considerations for Extraesophageal Symptoms

For chronic cough, laryngitis, or asthma attributed to GERD:

• More intensive therapy is required: twice-daily PPI dosing for 8-12 weeks minimum 1, 2
• Combine with strict antireflux diet (≤45g fat/day, eliminate all trigger foods) 1, 2
• Add prokinetic therapy if PPI alone is ineffective 1, 2
• Allow 1-3 months for response assessment—extraesophageal symptoms respond more slowly than typical heartburn 1, 2
• Response rates are lower for extraesophageal symptoms compared to typical GERD 1

Long-Term Management

Once symptoms are controlled:

• Taper to the lowest effective PPI dose to minimize potential long-term risks while maintaining symptom control 1, 2
• Periodically reassess the need for continued PPI therapy—some patients can discontinue or reduce dosing 1, 2
• Exceptions requiring long-term PPI: Los Angeles grade B or greater esophagitis, Barrett's esophagus, or peptic stricture 6
• PPIs have safety profiles comparable to placebo for short-term use 6

Common Pitfalls to Avoid

• Do not use metoclopramide as monotherapy or adjunctive therapy due to unfavorable risk-benefit profile 1
• Do not use P-CABs (like vonoprazan) as first-line therapy—they have higher costs, less availability, and less robust long-term safety data than PPIs 1
• Do not conclude PPI failure without verifying proper timing (30-60 minutes before meals) and adequate duration (4-8 weeks minimum) 2
• Do not recommend prone positioning for infants due to sudden infant death syndrome risk 1