GERD Treatment
Start with a proton pump inhibitor (PPI) taken 30-60 minutes before breakfast as first-line therapy, combined with weight loss if overweight and head of bed elevation for nighttime symptoms. 1
First-Line Pharmacological Treatment
PPIs are the most effective medical treatment for GERD, superior to H2-receptor antagonists and placebo for both healing esophagitis and achieving symptomatic relief. 1
Standard initial dosing:
- Omeprazole 20 mg once daily OR lansoprazole 30 mg once daily 2, 3, 4
- Take 30-60 minutes before breakfast for optimal acid suppression 1, 5
- Continue for 4-8 weeks initially 1, 5
For patients with typical GERD symptoms (heartburn, regurgitation) without alarm features, empiric PPI therapy is appropriate without requiring endoscopy first. 1
Essential Lifestyle Modifications
Weight loss has the strongest evidence for efficacy and should be recommended for all overweight or obese patients—this can prevent or postpone the need for acid suppression. 1, 6, 7
Head of bed elevation by 6-8 inches improves esophageal pH profiles and is specifically recommended for patients with nighttime heartburn or regurgitation. 1, 6
Avoid lying down for 2-3 hours after meals to reduce esophageal acid exposure by 30-50%. 1, 2
Dietary modifications should focus on:
- Limiting fat intake to less than 45 grams per 24 hours 8, 1
- Avoiding individual trigger foods that consistently provoke symptoms (coffee, chocolate, alcohol, citrus, tomatoes, spicy foods) rather than broadly restricting all patients 1, 9
- No smoking and limiting alcohol consumption 1, 2
Treatment Escalation for Persistent Symptoms
If symptoms persist after 4 weeks of standard once-daily PPI therapy:
Increase to twice-daily PPI dosing—one dose before breakfast and one before dinner. 1, 5
Verify compliance and timing—ensure the patient is taking PPI 30-60 minutes before meals, as improper timing is a common cause of treatment failure. 5
Consider endoscopy after failed empiric therapy to assess for esophagitis, Barrett's esophagus, or alternative diagnoses. 1
Add prokinetic therapy to PPI treatment for patients with persistent symptoms despite optimized PPI therapy. 8, 1 However, avoid metoclopramide due to unfavorable risk-benefit profile including tardive dyskinesia risk. 1
Implement a strict antireflux diet including ≤45g fat/day, eliminating coffee, tea, soda, chocolate, mints, citrus products, and alcohol. 8, 1
Special Considerations for Extraesophageal Symptoms
For chronic cough, laryngitis, or asthma attributed to GERD, more intensive therapy is required:
- Twice-daily PPI dosing for 8-12 weeks minimum 8, 1, 5
- Response rates are lower for extraesophageal symptoms compared to typical GERD symptoms 1, 5
- Allow 1-3 months to assess response before escalating treatment 8
- If cough persists after 3 months of maximal medical therapy, consider 24-hour esophageal pH monitoring 8
Long-Term Management
After achieving symptom control, taper to the lowest effective PPI dose to minimize potential long-term risks while maintaining control. 1, 2
Periodically reassess the need for continued therapy—some patients may be able to discontinue or reduce dosing. 1, 2
For confirmed erosive esophagitis or Barrett's esophagus, long-term PPI therapy is generally required and benefits outweigh risks, including potential concerns about impaired cognition, bacterial gastroenteritis, community-acquired pneumonia, hip fractures, vitamin B12 deficiency, hypomagnesemia, and chronic kidney disease. 1, 2
Surgical Options
Antireflux surgery should be considered for patients with objectively documented GERD who fail maximal medical therapy for at least 3 months. 8, 1
Surgery improves or cures symptoms in 85-86% of properly selected patients who have failed intensive medical therapy. 8, 1
Surgical options include:
- Laparoscopic fundoplication (often utilized in non-obese patients) 5
- Magnetic sphincter augmentation 5
- Transoral incisionless fundoplication (for carefully selected patients without hiatal hernia) 5
- Roux-en-Y gastric bypass (effective as primary anti-reflux intervention in obese patients) 5
Common Pitfalls to Avoid
Do not add nocturnal H2-receptor antagonist to twice-daily PPI as standard practice—there is no evidence of improved efficacy with this combination. 8, 1
Do not rely on acid suppression alone for extraesophageal symptoms, as this may fail to adequately control symptoms and potentially place patients at increased risk of community-acquired pneumonia. 8
Address comorbid conditions that worsen GERD, such as obstructive sleep apnea, and medications like nitrates, progesterone, and calcium channel blockers. 8, 1
Recognize that coughing can induce reflux events, creating a self-perpetuating cycle unless all causes of cough are adequately treated. 8