Is it reasonable to increase the Proton Pump Inhibitor (PPI) dose for a 61-year-old patient with Gastroesophageal Reflux Disease (GERD) complaining of globus sensation, currently on Prilosec (omeprazole) 20mg twice a day?

Increasing PPI Dose for Globus in GERD

No, it is not reasonable to simply increase the PPI dose for this patient already on omeprazole 20mg twice daily with persistent globus sensation—instead, you should first confirm that GERD is actually causing her globus through objective testing (endoscopy and pH monitoring off PPI), as globus is an isolated extra-esophageal symptom that often has non-GERD etiologies. 1, 2

Why Dose Escalation is Not the Right Next Step

Your patient is already on omeprazole 40mg daily (20mg BID), which exceeds the FDA-approved dosing for GERD and represents an aggressive acid suppression regimen. 1, 3 The 2022 AGA guidelines explicitly state that clinicians should perform upfront objective reflux testing off medication (rather than empiric PPI escalation) in patients with isolated extra-esophageal symptoms like globus. 1, 4

Key Problem with Globus as a Symptom

• Globus sensation is an isolated extra-esophageal symptom that has poor correlation with acid exposure and often represents functional disorders rather than true GERD 1
• The positive predictive value of atypical symptoms for GERD is highly variable, making empiric therapy unreliable 5
• Continuing to escalate PPI therapy without objective confirmation wastes time, exposes the patient to unnecessary medication risks, and delays appropriate treatment if the underlying cause is non-GERD 2, 4

The Correct Diagnostic Approach

Step 1: Upper Endoscopy First

Perform upper endoscopy to assess for:

• Erosive esophagitis using Los Angeles classification 2, 4
• Barrett's esophagus with Prague classification 2
• Hiatal hernia size and Hill grade of the flap valve 2

If endoscopy shows Los Angeles Grade B or higher esophagitis or long-segment Barrett's (≥3cm), GERD is confirmed and you can proceed with treatment optimization. 2, 4

Step 2: pH Monitoring if Endoscopy is Normal or Shows Only LA Grade A

If endoscopy is normal or shows only LA Grade A esophagitis, perform prolonged wireless pH monitoring OFF PPI (96-hour monitoring preferred, minimum 48 hours) to objectively confirm whether GERD exists. 1, 2, 4

Interpretation of pH monitoring:

• AET <4.0% on all days = No GERD → Stop PPI, consider functional disorder 1
• AET ≥6.0% on ≥2 days = Confirmed GERD → Optimize therapy 1
• AET ≥4.0% but not meeting GERD criteria = Borderline GERD → Optimize PPI and lifestyle modifications 1

If GERD is Confirmed: Treatment Optimization (Not Just Dose Increase)

Before Increasing Dose, Verify Compliance and Timing

The most common reason for PPI failure is improper timing—confirm she takes omeprazole 30 minutes before meals. 2, 4 Improper timing dramatically reduces efficacy.

Personalized Adjunctive Therapy (Not Just More PPI)

Rather than blindly increasing PPI dose, personalize adjunctive pharmacotherapy to her specific symptom pattern: 1

• For globus/throat symptoms specifically: Consider baclofen for regurgitation or belch-predominant symptoms (though side effects may limit use) 1
• For breakthrough symptoms: Add alginate antacids 1, 2
• For nocturnal symptoms: Add nighttime H2 receptor antagonist 1
• If gastroparesis suspected: Consider prokinetics 1

Consider Behavioral/Neuromodulation Approaches

Globus often has a functional or hypersensitivity component even when GERD is present. 1 Consider:

• Pharmacologic neuromodulation with low-dose antidepressants 1, 4
• Referral for cognitive behavioral therapy, esophageal-directed hypnotherapy, or diaphragmatic breathing exercises 1, 4

If No GERD is Found: Stop the PPI

If pH monitoring shows physiologic acid exposure (AET <4.0% on all days) with normal endoscopy, this patient does NOT have GERD and likely has a functional esophageal disorder. 1

In this scenario:

• Wean off PPI therapy 1
• Refer to GI psychology for cognitive behavioral therapy or esophageal-directed hypnotherapy 1, 4
• Consider pharmacologic neuromodulation 1, 4
• Evaluate for rumination syndrome or esophageal motility disorders with high-resolution manometry 1

Critical Pitfalls to Avoid

• Never empirically escalate PPI dosing beyond twice-daily without objective confirmation of GERD 2, 4
• Do not continue long-term PPI without establishing definitive diagnosis through endoscopy and possibly pH monitoring 2, 4
• Recognize that she is already on a high dose (40mg daily total)—further escalation is not FDA-approved and unlikely to help if the problem is non-GERD 1, 3
• Avoid the trap of treating symptoms indefinitely without confirming the underlying pathophysiology 2, 4

Bottom Line Algorithm

1. Stop and reassess—she's already on aggressive therapy (omeprazole 20mg BID = 40mg daily total)
2. Perform upper endoscopy to look for objective evidence of GERD 2, 4
3. If endoscopy normal/LA Grade A only: Perform prolonged pH monitoring OFF PPI 1, 2, 4
4. If GERD confirmed: Optimize with proper timing, adjunctive therapy, and behavioral approaches—not just more PPI 1, 2
5. If no GERD: Wean PPI and treat as functional disorder 1, 4