What's the next step for a patient with Gastroesophageal Reflux Disease (GERD) who didn't respond to omeprazole (proton pump inhibitor) after trying dexilant (dexlansoprazole)?

Next Step for PPI-Refractory GERD

Increase omeprazole to twice daily dosing (20 mg BID) as the immediate next step, as this is the guideline-recommended approach for patients failing once-daily PPI therapy. 1, 2

Optimize Current PPI Therapy

• Double the PPI dose to twice daily before considering the patient a treatment failure, as persistent symptoms on once-daily dosing are common and do not indicate true PPI resistance 1
• The British Society of Gastroenterology specifically recommends increasing to twice-daily dosing in patients with persistent symptoms on once-daily PPI, as this is more logical and cost-effective than immediately pursuing diagnostic testing 1
• Assess compliance first, as non-adherence is a common cause of apparent PPI failure 2
• Extend treatment duration to 2-3 months before declaring treatment failure, as some patients require this longer period for symptom improvement 1, 2

If Twice-Daily PPI Fails After Adequate Trial

Consider Adding Adjunctive Therapies

• Add a prokinetic agent (domperidone, mosapride, or itopride) to enhance gastric motility and reduce reflux episodes 1, 2
• Add sodium alginate to PPI therapy, which significantly improves heartburn resolution in PPI-refractory patients by displacing the postprandial acid pocket below the diaphragm 2
• H2-receptor antagonists can be added for additional symptom control, though evidence is modest 2

Implement Aggressive Lifestyle Modifications

• Limit dietary fat to <45 g per 24 hours and eliminate coffee, tea, soda, chocolate, mints, citrus products, and alcohol 2
• Elevate the head of bed and avoid tight clothing 1, 2

Diagnostic Testing for Persistent Symptoms

• Perform pH/impedance monitoring (not pH monitoring alone) in patients not responding to twice-daily PPI therapy 1
• This testing should be done while on twice-daily PPI to identify non-acid reflux, which occurs in approximately 60% of non-erosive reflux disease patients refractory to PPIs 1
• pH/impedance monitoring is superior to pH monitoring alone because it detects non-acid reflux episodes that pH monitoring misses, reducing false negative studies 1
• Testing helps classify patients into phenotypes: non-erosive reflux disease, hypersensitive esophagus, or functional heartburn, which guides further therapy 1

Surgical Consideration for True Refractory Cases

• Laparoscopic fundoplication should be considered for patients with objectively documented GERD who fail intensive medical therapy 1, 2
• Surgery improves or eliminates chronic reflux symptoms in 85-86% of patients at 6-12 months who failed intensive medical therapy 1, 2
• Never proceed to surgery without objective documentation of GERD through pH/impedance monitoring or endoscopy showing Los Angeles Grade B or higher esophagitis 1, 2

Critical Pitfalls to Avoid

• Don't assume treatment failure prematurely: Many patients require 2-3 months for symptom improvement, and standard once-daily PPI dosing is often inadequate 1, 2
• Don't rely on acid suppression alone: Non-acid reflux may be the culprit in PPI-refractory cases, requiring prokinetic therapy or surgery 1, 2
• Don't switch between different PPIs without optimizing dosing first: While dexlansoprazole has a dual delayed-release formulation providing prolonged acid suppression 3, 4, the evidence-based approach is to optimize the current PPI with twice-daily dosing before switching agents 1
• Don't order testing in patients responding to therapy: Reflux monitoring is not recommended in patients with symptoms responsive to PPI therapy unless antireflux surgery is planned 1