What is the management for gastroesophageal reflux disease (GERD)?

Management of Gastroesophageal Reflux Disease (GERD)

Start with lifestyle modifications and empiric proton pump inhibitor (PPI) therapy for patients with typical GERD symptoms (heartburn and regurgitation) without alarm features, as PPIs are the most effective first-line pharmacological treatment. 1, 2

Initial Management Approach

Lifestyle Modifications (First-Line for All Patients)

• Weight loss is the single most effective lifestyle intervention for overweight or obese patients with GERD, with the strongest evidence for efficacy and can prevent or postpone the need for acid suppression. 1, 3
• Elevate the head of the bed 6-8 inches for patients with nighttime heartburn or regurgitation, as this improves esophageal pH profiles. 1, 2, 3
• Avoid lying down for 2-3 hours after meals to reduce esophageal acid exposure. 1, 2
• Avoid specific trigger foods that consistently provoke symptoms in individual patients (coffee, chocolate, alcohol, spicy foods, citrus, tomatoes) rather than broadly restricting all foods. 1, 2
• Limit fat intake to less than 45g per day as part of an antireflux diet. 1
• Smoking cessation and limiting alcohol consumption are recommended, though evidence for symptom improvement is limited. 1, 3

Pharmacologic Treatment Algorithm

Step 1: Initial PPI Therapy

• Start omeprazole 20 mg or lansoprazole 30 mg once daily, taken 30-60 minutes before breakfast for optimal acid suppression. 1, 2, 4, 5, 6
• Treat for 4-8 weeks initially for typical GERD symptoms without performing endoscopy, as typical symptoms are approximately 70% sensitive and specific for objective GERD. 1, 2
• PPIs are superior to H2-receptor antagonists (H2RAs) and placebo for both healing esophagitis and achieving symptomatic relief. 1

Step 2: Assess Response and Optimize Therapy

• If symptoms persist after 4 weeks of standard once-daily PPI dosing, escalate to twice-daily dosing (one dose before breakfast and one before dinner). 1, 2
• Ensure proper timing and compliance before increasing dose, as improper timing is a common cause of treatment failure. 1, 7
• After symptom control is achieved, taper to the lowest effective dose that maintains symptom control. 1, 2

Step 3: Management of Persistent Symptoms

• Perform endoscopy if symptoms persist despite optimized twice-daily PPI therapy to assess for erosive disease, Barrett's esophagus, or alternative diagnoses. 1, 2
• Consider 24-hour esophageal pH monitoring off PPI therapy in patients without erosive disease on endoscopy to confirm GERD diagnosis. 2
• Add bedtime H2RA (famotidine) for nighttime breakthrough symptoms, though tachyphylaxis may develop with continued use. 2, 4
• Consider adding sodium alginate to PPI for rapid relief of breakthrough symptoms, particularly in patients with non-erosive reflux disease. 2, 4

Special Clinical Scenarios

Extraesophageal GERD Symptoms (Chronic Cough, Laryngitis, Asthma)

• More intensive therapy is required, including twice-daily PPI dosing for a minimum of 8-12 weeks. 1
• Implement a strict antireflux diet (≤45g fat/day, no coffee, tea, soda, chocolate, mints, citrus products, alcohol). 1
• Response rates are significantly lower for extraesophageal symptoms compared to typical GERD symptoms. 1
• Address comorbid conditions such as obstructive sleep apnea that may exacerbate GERD. 1
• Allow 1-3 months to assess response before escalating treatment. 1
• Consider antireflux surgery in properly selected patients who fail at least 3 months of intensive medical therapy, with surgery showing improvement or cure of cough in 85-86% of appropriate candidates. 1

Pediatric GERD Management

• Distinguish between physiologic gastroesophageal reflux (GER) and GERD (reflux associated with troublesome symptoms or complications), as conservative management is appropriate for uncomplicated GER. 8
• Lifestyle changes are first-line therapy for both GER and GERD in pediatric patients. 8
• Medications are explicitly indicated only for patients with GERD, not physiologic reflux. 8
• For infants, consider smaller, more frequent feedings and keeping infant upright after feeds. 2
• For formula-fed infants, consider thickened feedings or trial of extensively hydrolyzed protein formula if milk protein allergy is suspected. 2
• Use acid suppressants (H2RAs, PPIs) judiciously in pediatric patients due to concerns about inappropriate prescriptions. 8
• Surgical therapies are reserved for children with intractable symptoms or life-threatening complications of GERD. 8

Erosive Esophagitis

• Acid suppression with PPIs is essential, as lifestyle modifications alone are insufficient for documented esophagitis. 1
• Treat for 4-8 weeks initially, with an additional 4 weeks if healing is incomplete. 5, 6
• Long-term PPI therapy is generally required for confirmed erosive esophagitis or Barrett's esophagus, and benefits outweigh risks. 1

Common Pitfalls and Caveats

What NOT to Do

• Do not use metoclopramide as monotherapy or adjunctive therapy for GERD due to unfavorable risk-benefit profile, including risk of tardive dyskinesia. 1
• Do not add nocturnal H2RA to twice-daily PPI as standard practice, as there is no evidence of improved efficacy with this combination. 1
• Do not use doses higher than standard PPI dosing without first optimizing timing and ensuring twice-daily dosing. 1
• Do not broadly recommend all lifestyle modifications to every GERD patient, as evidence does not support this approach and leads to poor compliance. 1
• Do not use P-CABs (vonoprazan) as first-line therapy for uninvestigated heartburn or non-erosive GERD due to higher costs, less availability, and less robust long-term safety data compared to PPIs. 1

Long-Term Management Considerations

• Periodically reassess the need for continued PPI therapy and attempt to use the lowest effective dose to minimize potential long-term risks. 1, 2
• For patients on long-term PPI therapy (>12 months), offer objective reflux testing to confirm the GERD diagnosis. 2, 4
• Potential long-term PPI risks include impaired cognition, bacterial gastroenteritis, community-acquired pneumonia, hip fractures, vitamin B12 deficiency, hypomagnesemia, and chronic kidney disease, though these observational findings need confirmation before influencing clinical decision-making. 1, 9

Surgical and Endoscopic Options

• Laparoscopic fundoplication may be considered for patients with objectively documented GERD that fails maximal medical therapy for at least 3 months. 1, 2
• Surgery is appropriate for young, healthy patients with confirmed severe GERD or those at risk for life-threatening complications. 8, 9
• Magnetic sphincter augmentation and endoscopic therapies are emerging options, but long-term safety and efficacy remain to be established. 7, 9

Functional Heartburn and Esophageal Hypersensitivity

• For patients with normal acid exposure on pH testing and negative symptom association, consider functional heartburn or esophageal hypersensitivity. 2, 4
• Consider neuromodulators (tricyclic antidepressants, selective serotonin reuptake inhibitors) or psychological interventions for functional esophageal disorders. 2, 7
• SSRIs do not contraindicate standard GERD management and may serve as neuromodulators if functional esophageal disorder is present. 4