What is the drug of choice for Gastroesophageal Reflux Disease (GERD)?

Drug of Choice for GERD

Proton pump inhibitors (PPIs) are the drug of choice for GERD, with omeprazole and lansoprazole being the most established first-line agents for both adults and children. 1

Initial Treatment Approach for Adults

For patients presenting with typical GERD symptoms (heartburn, regurgitation) without alarm features, initiate a 4- to 8-week trial of single-dose PPI therapy taken 30-60 minutes before a meal. 1

• Any commercially available PPI (omeprazole, lansoprazole, esomeprazole, pantoprazole, rabeprazole) can be used initially, as all demonstrate similar efficacy at recommended dosages 2
• If inadequate response occurs after 4-8 weeks, escalate to twice-daily PPI dosing or switch to a more potent formulation 1
• Once symptoms are controlled, taper to the lowest effective dose for maintenance 1

Why PPIs Are Superior

PPIs provide more potent and prolonged gastric acid suppression compared to H2-receptor antagonists (H2RAs), resulting in faster symptom relief and higher healing rates. 2, 3

• For erosive esophagitis, PPIs achieve healing rates of 70-90% compared to 40-50% with H2RAs 4
• PPIs provide symptomatic improvement in 92% of patients versus 40-60% with H2RAs in severe GERD 4
• H2RAs develop tachyphylaxis (diminishing response) within 6 weeks, limiting long-term effectiveness 1, 5

Specific PPI Recommendations

Omeprazole and lansoprazole are FDA-approved for the broadest range of GERD indications and have the most extensive safety data. 6, 7

Omeprazole:

• FDA-approved for GERD treatment in patients ≥2 years of age 7
• Dosing: Adults typically 20-40 mg once daily; pediatric patients 0.7-3.3 mg/kg/day 5, 7
• Available as delayed-release capsules that can be opened and sprinkled on soft foods for children 5

Lansoprazole:

• FDA-approved for symptomatic GERD in adults and children ≥1 year 6
• Dosing: Adults 15-30 mg once daily; pediatric patients based on weight 6
• Effective for healing erosive esophagitis in 4-8 weeks 6

Role of H2-Receptor Antagonists

H2RAs (ranitidine, famotidine) are relegated to second-line therapy, appropriate only for mild, intermittent GERD symptoms. 4, 8

• Ranitidine 150 mg twice daily or famotidine 20-40 mg twice daily can be used for mild disease 9
• H2RAs are effective for symptomatic improvement in >70% of patients with nonerosive GERD but only 40-50% with erosive disease 4
• Development of tachyphylaxis limits their use for chronic management 1, 5

Pediatric Considerations

For children with GERD, omeprazole is the preferred PPI due to superior efficacy over H2RAs and FDA approval down to age 2 years. 5

• Start with lifestyle modifications (smaller frequent feedings, thickened formula, positioning) before pharmacotherapy 1, 5
• If pharmacotherapy needed, omeprazole 0.7-3.3 mg/kg/day is more effective than famotidine for symptom relief and healing erosive esophagitis 5
• Famotidine 1 mg/kg/day divided twice daily may be considered for mild symptoms, but switch to omeprazole if no response after 2-4 weeks 5

Treatment Algorithm for Refractory Cases

If symptoms persist despite twice-daily PPI therapy, perform objective testing (endoscopy and pH monitoring off PPI) to confirm GERD diagnosis before further escalation. 1

1. Verify medication adherence and proper timing (30-60 minutes before meals) 1
2. Rule out non-GERD causes (functional esophageal disorders, eosinophilic esophagitis) 1
3. Consider adding baclofen for persistent reflux symptoms, though side effects limit use 8
4. Evaluate for antireflux surgery if confirmed pathologic GERD with adequate esophageal peristalsis 1

Important Caveats

Avoid empiric long-term PPI therapy without objective confirmation of GERD diagnosis. 1

• If PPI therapy continues beyond 12 months in unproven GERD, perform endoscopy with prolonged wireless pH monitoring off PPI to establish appropriateness 1
• Prokinetic agents (metoclopramide) have not been proven effective for GERD symptom control and carry significant side effects 8
• For chronic cough attributed to GERD, intensive medical therapy including PPI, dietary modifications, and prokinetic agents may be needed, with omeprazole 40 mg twice daily used in refractory cases 1
• Lifestyle modifications (weight loss, head of bed elevation, avoiding meals within 3 hours of bedtime) should accompany pharmacotherapy 1