What is the recommended treatment for gastroesophageal reflux disease (GERD)?

Treatment of Gastroesophageal Reflux Disease (GERD)

Initiate a standard once-daily proton pump inhibitor (PPI) taken 30-60 minutes before breakfast for 4-8 weeks as first-line therapy for typical GERD symptoms (heartburn, regurgitation) without alarm features. 1, 2

Initial Pharmacologic Management

• PPIs are the most effective first-line treatment for GERD, superior to H2-receptor antagonists (H2RAs) and antacids for both symptom relief and healing of erosive esophagitis. 1, 3, 2
• Standard-dose PPI options include omeprazole 20mg, lansoprazole 30mg, or equivalent agents taken 30-60 minutes before the first meal of the day for optimal acid suppression. 2, 4, 5
• A 4-8 week trial is appropriate for initial treatment of typical GERD symptoms without performing endoscopy first. 1, 2
• After symptom resolution, taper to the lowest effective PPI dose that maintains symptom control to minimize long-term exposure. 1

Lifestyle Modifications (Targeted, Not Universal)

• Elevate the head of the bed by 6-8 inches specifically for patients with nighttime symptoms or regurgitation when lying down. 1, 3, 2
• Avoid lying down for 2-3 hours after meals to reduce esophageal acid exposure. 1, 3
• Weight loss is recommended for all overweight or obese patients with GERD, as this directly improves reflux. 1, 3
• Avoid specific trigger foods (coffee, alcohol, chocolate, spicy foods, citrus, tomatoes) only if they consistently provoke symptoms in that individual patient—blanket dietary restrictions are not evidence-based. 1, 3

Treatment Escalation for Persistent Symptoms

If symptoms persist after 4-8 weeks of once-daily PPI, increase to twice-daily dosing (before breakfast and dinner) before adding other medications. 1, 2

• The most common cause of treatment failure is medication non-compliance or improper timing—verify adherence and correct timing before escalating therapy. 1
• If symptoms persist after 8 weeks of twice-daily PPI therapy, perform upper endoscopy to exclude alternative diagnoses (eosinophilic esophagitis, pill esophagitis, stricture, Barrett's esophagus, malignancy). 1, 6
• Consider 24-hour pH-impedance monitoring (off PPI for 7 days) to confirm acid reflux as the cause and assess for non-acid reflux if endoscopy is normal. 1

Add-On Therapies for Refractory Symptoms

For nocturnal breakthrough symptoms despite twice-daily PPI, add an H2RA at bedtime (e.g., famotidine 20-40mg), though tachyphylaxis limits long-term efficacy. 1

• Alginate-based products (e.g., Gaviscon) form a physical barrier to reflux and may provide additional benefit when added to PPI, though evidence is mixed. 1
• Baclofen 5-20mg three times daily reduces transient lower esophageal sphincter relaxations but causes significant side effects (somnolence, dizziness, weakness) that limit its use. 1
• Avoid metoclopramide due to unfavorable risk-benefit profile, including risk of tardive dyskinesia. 3

Surgical Management

Antireflux surgery (laparoscopic fundoplication or magnetic sphincter augmentation) should be recommended for patients who are responsive to but intolerant of PPI therapy. 6

• Surgery is also appropriate for patients with persistent troublesome symptoms (especially regurgitation) despite twice-daily PPI therapy after objective confirmation of GERD with endoscopy and pH monitoring. 6
• When PPI therapy and surgery offer similar efficacy, PPI therapy should be recommended as initial therapy due to superior safety—surgery carries risks of new symptoms including dysphagia, flatulence, inability to belch, and bowel symptoms. 6
• Do not perform antireflux surgery in patients who are symptomatically well-controlled on medical therapy or as an antineoplastic measure in Barrett's esophagus. 6
• Patients must have objective documentation of GERD (abnormal pH monitoring or erosive esophagitis on endoscopy) and preserved esophageal peristalsis on manometry before surgery. 6

Special Considerations for Extraesophageal GERD Symptoms

For suspected extraesophageal GERD manifestations (chronic cough, laryngitis, asthma), use twice-daily PPI therapy for a minimum of 8-12 weeks before concluding treatment failure. 6, 3, 2

• Extraesophageal symptoms have lower response rates to PPI therapy compared to typical GERD symptoms. 3, 2
• Twice-daily PPI is strongly recommended as an empirical trial for suspected reflux chest pain syndrome after cardiac etiology has been carefully excluded. 6
• For extraesophageal symptoms with concomitant typical GERD symptoms, maintenance PPI therapy is appropriate; however, do not use once- or twice-daily PPIs for isolated extraesophageal symptoms without concomitant esophageal GERD syndrome. 6
• Consider antireflux surgery for extraesophageal symptoms refractory to 3 months of intensive medical therapy (twice-daily PPI, strict antireflux diet with ≤45g fat/day, lifestyle modifications), though the balance of benefits and harms is close. 6, 3

Long-Term Management and Safety

• Chronic PPI therapy is appropriate for adequate symptom control in most patients with GERD severe enough to warrant initial PPI therapy. 1
• For patients requiring long-term PPI therapy (>12 months), consider objective reflux testing with endoscopy and pH monitoring to confirm GERD diagnosis. 1
• PPIs are generally safe for long-term use—the most established risks are slight increases in C. difficile colitis and bacterial gastroenteritis, but absolute risks remain small. 1
• On-demand therapy (taking medication only when symptoms occur) is reasonable for non-erosive GERD but not recommended for documented erosive esophagitis. 1
• Periodically reassess the need for continued PPI therapy to use the lowest effective dose. 1, 2

Screening for Barrett's Esophagus and Malignancy

• There is insufficient evidence to recommend routine endoscopic screening for Barrett's esophagus in adults ≥50 years with 5-10 years of heartburn to reduce mortality from esophageal adenocarcinoma. 6
• The principal use of endoscopy in GERD is evaluation of treatment failures and risk management, not routine screening. 6
• For patients with Barrett's esophagus, long-term PPI therapy is required for symptom control, though PPIs do not prevent progression to dysplasia or adenocarcinoma. 6

Common Pitfalls to Avoid

• Do not add medications without first optimizing PPI dosing and verifying compliance—this is the most common cause of treatment failure. 1
• Do not perform endoscopy as initial diagnostic test in uncomplicated GERD—empiric PPI therapy is appropriate first-line management. 1, 2
• Do not use prokinetic agents (metoclopramide) as they have not been proven effective and carry significant risks. 3, 7
• Do not recommend universal dietary restrictions—only avoid specific trigger foods if they consistently provoke symptoms in that individual. 1, 3