What to prescribe for a patient with Gastroesophageal Reflux Disease (GERD) and globus sensation already taking omeprazole (Proton Pump Inhibitor (PPI)) 40 mg daily

Management of GERD with Globus Sensation on Omeprazole 40 mg Daily

Increase omeprazole to 40 mg twice daily (before breakfast and dinner) for 8-12 weeks, as this patient has failed standard once-daily therapy and requires dose escalation before pursuing diagnostic workup. 1, 2

Rationale for Dose Escalation

The patient is currently on omeprazole 40 mg daily, which is already double the FDA-approved standard dose of 20 mg for GERD 3. However, expert consensus unanimously recommends twice-daily PPI dosing for patients with inadequate response to once-daily therapy, despite limited clinical trial data supporting this approach 1. The American Gastroenterological Association guidelines specifically state that patients whose symptoms have not adequately responded to once-daily dosing should receive twice-daily PPI therapy before being considered treatment failures 1.

Critical Timing Considerations

• Allow 8-12 weeks on twice-daily dosing before declaring treatment failure, as globus sensation and extraesophageal GERD symptoms often require 2-3 months of adequate acid suppression before improvement occurs 1, 2
• The standard 4-8 week trial used for typical heartburn is insufficient for globus symptoms 1, 2
• Ensure the patient takes omeprazole 30-60 minutes before meals (not at bedtime) for optimal acid suppression 2, 4

If Symptoms Persist After Twice-Daily PPI Trial

Proceed to diagnostic evaluation rather than adding adjunctive medications empirically 1:

• Perform upper endoscopy to assess for erosive esophagitis (Los Angeles classification), hiatal hernia (Hill grade), and Barrett's esophagus (Prague classification) 1
• If endoscopy is normal or shows only mild disease (LA grade A), perform 96-hour wireless pH monitoring OFF PPI therapy to confirm true GERD versus functional disorder 1
• Consider high-resolution esophageal manometry if pH testing is negative, as globus can result from subtle motility disorders 1

What NOT to Do

• Do not add metoclopramide - it is specifically recommended against (Grade D) for GERD management due to unfavorable risk-benefit profile 1
• Do not add nighttime H2-receptor antagonists - there is no evidence of improved efficacy when adding H2RAs to twice-daily PPI therapy 1
• Do not empirically add baclofen or prokinetics without objective testing confirming the mechanism of symptoms 1

Common Pitfalls

• Mistiming PPI administration: Taking omeprazole at bedtime rather than before meals dramatically reduces efficacy 2, 4
• Premature diagnostic testing: Performing endoscopy before completing an adequate therapeutic trial wastes resources 1
• Assuming globus equals GERD: Up to 50% of patients with globus sensation may have functional disorders or reflux hypersensitivity rather than true acid reflux 1
• Polypharmacy without evidence: Adding multiple agents (H2RAs, prokinetics, alginates) without objective testing leads to unnecessary medication burden and cost 1

Lifestyle Modifications to Emphasize

• Weight loss if BMI >25 - this may prevent or postpone the need for continued acid suppression 1
• Elevate head of bed 6-8 inches if the patient has nighttime symptoms 1
• Avoid specific triggers only if the patient identifies consistent symptom provocation (alcohol, coffee, spicy foods) 1

Long-Term Management Considerations

If the patient achieves symptom control on twice-daily therapy and endoscopy shows no erosive disease or Barrett's esophagus, attempt de-escalation after 3-6 months of symptom control by stepping down to once-daily dosing, then potentially to on-demand therapy 1, 2. However, if erosive esophagitis (LA grade B or higher) or Barrett's esophagus is found, the patient requires indefinite daily PPI therapy 1, 2.