What is the best treatment for acid reflux?

Best Treatment for Acid Reflux (GERD)

Proton pump inhibitors (PPIs) taken once daily, 30-60 minutes before breakfast, are the most effective first-line treatment for gastroesophageal reflux disease, superior to H2-receptor antagonists and placebo for both symptom relief and healing of esophagitis. 1

Initial Pharmacological Treatment

• Start with omeprazole 20 mg or lansoprazole 30 mg once daily, taken 30-60 minutes before the first meal of the day to optimally suppress acid production 1, 2
• For patients with typical GERD symptoms (heartburn and regurgitation), empiric PPI therapy is appropriate without initial endoscopy 1, 2
• Allow 4 weeks to assess response before escalating therapy 1

Essential Lifestyle Modifications

Weight loss is the single most effective lifestyle intervention and should be recommended to all overweight or obese patients with GERD, as it has the strongest evidence for efficacy and can prevent or delay the need for acid suppression 1, 2

Additional lifestyle measures with proven benefit include:

• Elevate the head of the bed by 6-8 inches for patients with nighttime symptoms or regurgitation that disturbs sleep 1, 2
• Avoid lying down for 2-3 hours after meals to reduce esophageal acid exposure by 30-50% 1, 2
• Avoid trigger foods on an individualized basis (coffee, chocolate, alcohol, spicy foods, citrus, tomatoes) 1
• Complete smoking cessation (not just reduction) 3

Treatment Escalation for Persistent Symptoms

If symptoms persist after 4 weeks of standard once-daily PPI:

• Escalate to twice-daily PPI dosing (one dose before breakfast, one before dinner), which is superior to once-daily dosing for acid suppression 1, 2
• Consider endoscopy after failed empiric therapy to assess for esophagitis or other pathology 1
• For refractory cases, implement a strict antireflux diet (≤45g fat per day, eliminate coffee, tea, soda, chocolate, mints, citrus products, alcohol) 1, 3

Special Considerations for Extraesophageal Symptoms

For patients with suspected GERD-related chronic cough, laryngitis, or asthma:

• More aggressive initial therapy is required: twice-daily PPI for 8-12 weeks minimum 4, 1, 3
• Response rates are significantly lower than for typical GERD symptoms 1, 2
• Consider diagnostic testing for reflux before initiating PPI therapy in patients with potential extraesophageal manifestations but without typical GERD symptoms 4
• If symptoms fail to improve after one trial (up to 12 weeks) of PPI therapy, consider objective testing for pathologic reflux, as additional trials of different PPIs are low yield 4

Long-Term Management

• After initial symptom control, titrate to the lowest effective PPI dose that maintains symptomatic control 1, 2
• Periodically reassess the need for continued PPI therapy to minimize potential long-term risks 1, 2
• For confirmed erosive esophagitis or Barrett's esophagus, long-term PPI therapy is generally required, and benefits outweigh risks 1, 2

Important Safety Considerations

Be aware of potential long-term PPI risks, though benefits generally outweigh risks for appropriate indications 5, 6:

• Vitamin B12 deficiency (with use >3 years) 5, 6
• Hypomagnesemia (typically after ≥3 months, most commonly after 1 year) 5, 6
• Increased risk of Clostridium difficile-associated diarrhea 6
• Increased risk of osteoporosis-related fractures with high-dose, long-term use 6
• Fundic gland polyps with long-term use, especially beyond one year 5, 6
• Cutaneous and systemic lupus erythematosus (rare) 5, 6

Use the shortest duration of PPI therapy appropriate to the condition being treated 5, 6

When to Consider Surgical Referral

Antireflux surgery should be considered for patients who meet ALL of the following criteria 1, 3, 2:

• Objective documentation of persistent GERD on testing (endoscopy and/or 24-hour pH monitoring)
• Failed minimum 3 months of intensive medical therapy (twice-daily PPI, strict antireflux diet, lifestyle modifications)
• Significant quality of life impairment

A lack of response to PPI therapy predicts lack of response to antireflux surgery and should be incorporated into the decision process 4

Common Pitfalls to Avoid

• Do not use metoclopramide as monotherapy or adjunctive therapy for GERD due to unfavorable risk-benefit profile, including risk of tardive dyskinesia 1
• Avoid concomitant use of omeprazole with clopidogrel, as omeprazole inhibits the conversion of clopidogrel to its active metabolite 5
• Do not broadly recommend all lifestyle modifications to every patient; focus on weight loss and head of bed elevation, which have the strongest evidence 1
• Do not add nocturnal H2RA to twice-daily PPI as standard practice, as there is no evidence of improved efficacy 1