What is the recommended management and dosage for Gastroesophageal Reflux Disease (GERD)?

GERD Management and Dosage

Start all patients with typical GERD symptoms (heartburn, regurgitation) on a single-dose PPI taken 30-60 minutes before breakfast for 4-8 weeks, then reassess and titrate to the lowest effective dose. 1

Initial Management Approach

Patient Education (First Visit)

• Provide standardized education on GERD mechanisms, emphasizing that gastroesophageal reflux is a physiologic process controlled by protective factors like the anti-reflux barrier and esophageal peristalsis. 1
• Discuss lifestyle modifications including weight management, avoiding meals within 3 hours of bedtime, elevating the head of bed, and stress-reduction strategies. 1
• Reassure patients about PPI safety to improve adherence. 1

Lifestyle Modifications

• Weight loss for obese patients decreases esophageal acid exposure (from 5.6% to 3.7% in trials) and reduces reflux symptoms. 2
• Tobacco cessation reduces reflux symptoms significantly in normal-weight individuals (odds ratio 5.67). 2
• Avoid late evening meals - eating early decreases supine acid exposure by 5.2 percentage points compared to late meals. 2
• Head-of-bed elevation decreases supine acid exposure from 21% to 15%. 2

First-Line Pharmacotherapy

PPI Dosing

• Initial dose: Any commercially available PPI, 20 mg omeprazole equivalent once daily, taken 30-60 minutes before the first meal. 1, 3
• Treatment duration: 4-8 weeks initially. 1, 3
• Reassess after 4-8 weeks and titrate to the lowest effective dose if symptoms resolve. 1

If Inadequate Response After 4-8 Weeks

• Increase to twice-daily PPI (before breakfast and dinner) OR switch to a more potent PPI (esomeprazole, dexlansoprazole, or rabeprazole). 1, 4
• Ensure proper timing: 30-60 minutes before meals. 1, 5

Adjunctive Therapies (Personalized to Symptom Pattern)

For Breakthrough Symptoms on PPI

• Alginate-containing antacids are first-line for PRN breakthrough symptoms - they create a protective "raft" that neutralizes the postprandial acid pocket. 4, 6
• Particularly effective for post-prandial symptoms, nighttime symptoms, and patients with hiatal hernias. 4, 6

For Nocturnal Symptoms

• H2-receptor antagonists (famotidine, ranitidine) as-needed at bedtime. 4, 6
• Caution: H2RA efficacy diminishes with regular use due to tachyphylaxis; avoid adding nocturnal H2RA to twice-daily PPI (no proven benefit). 6

For Regurgitation or Belch-Predominant Symptoms

• Baclofen 5-20 mg three times daily. 4, 5

For Coexistent Gastroparesis

• Prokinetics may be considered. 4
• Avoid metoclopramide due to unfavorable risk-benefit profile. 6

When to Pursue Objective Testing

Indications for Endoscopy and pH Monitoring

• PPI non-responders after 4-8 weeks of twice-daily therapy. 1, 5
• Alarm symptoms (dysphagia, weight loss, bleeding, anemia). 1
• Isolated extra-esophageal symptoms (chronic cough, laryngitis) - perform upfront testing rather than empiric PPI trial. 1
• Before long-term PPI therapy in patients with unproven GERD - offer testing within 12 months of PPI initiation to establish appropriateness. 1

Testing Protocol

• Endoscopy to assess for erosive esophagitis (Los Angeles B or greater), Barrett's esophagus (≥3 cm), or hiatal hernia. 1, 5
• 96-hour wireless pH monitoring OFF PPI (preferred) if no erosive disease or long-segment Barrett's found, to confirm and phenotype GERD. 1
• pH-impedance monitoring ON PPI for refractory symptoms to determine if persistent symptoms are acid or non-acid related. 5

Management of Refractory GERD

If Symptoms Persist Despite Twice-Daily PPI

• Do not continue empiric therapy - objective testing is mandatory. 5
• Perform endoscopy and pH-impedance monitoring on PPI to phenotype the patient. 5

Based on Testing Results:

• Confirmed pathological acid reflux: Switch to different PPI (esomeprazole or dexlansoprazole). 5
• Non-acid reflux or hypersensitive esophagus: Add neuromodulators (tricyclic antidepressants or SSRIs). 5
• Functional heartburn: Pharmacologic neuromodulation and/or behavioral therapy referral. 5
• Persistent symptoms despite optimized medical therapy: Consider antireflux surgery. 5

Surgical Options (For Proven GERD)

Candidacy Requirements

• Confirmatory evidence of pathologic GERD on objective testing. 1
• Exclusion of achalasia. 1
• Assessment of esophageal peristaltic function. 1

Surgical Approaches

• Laparoscopic fundoplication (partial fundoplication preferred if esophageal hypomotility present). 1
• Magnetic sphincter augmentation (often with crural repair if hiatal hernia present). 1
• Transoral incisionless fundoplication (endoscopic option for carefully selected patients without hiatal hernia). 1
• Roux-en-Y gastric bypass for obese patients (effective primary anti-reflux intervention); avoid sleeve gastrectomy as it may worsen GERD. 1

Specific Dosing by Indication (Omeprazole as Reference)

Adults

• Symptomatic GERD: 20 mg once daily for up to 4 weeks. 3
• Erosive esophagitis: 20 mg once daily for 4-8 weeks. 3
• Maintenance of healing: 20 mg once daily (controlled studies don't extend beyond 12 months). 3
• Active duodenal ulcer: 20 mg once daily for 4 weeks. 3
• Active benign gastric ulcer: 40 mg once daily for 4-8 weeks. 3

Pediatrics (2-16 years)

• 10-20 kg: 10 mg once daily. 3
• ≥20 kg: 20 mg once daily. 3
• Duration: 4-8 weeks for erosive esophagitis, up to 4 weeks for symptomatic GERD. 3

Common Pitfalls to Avoid

• Incorrect PPI timing: Must be taken 30-60 minutes before meals, not at bedtime or with meals. 1, 5
• Continuing empiric therapy indefinitely: If planning long-term PPI, establish diagnosis with objective testing within 12 months. 1
• Adding nocturnal H2RA to twice-daily PPI: No evidence of benefit. 6
• Using metoclopramide routinely: Unfavorable risk-benefit profile. 6
• Ignoring lifestyle modifications: These are essential adjuncts, not optional. 1, 2