What are the treatment options for Gastroesophageal Reflux Disease (GERD)?

Treatment of Gastroesophageal Reflux Disease (GERD)

Start with proton pump inhibitors (PPIs) as first-line pharmacological therapy—specifically omeprazole 20 mg or lansoprazole 30 mg once daily, taken 30-60 minutes before breakfast—combined with weight loss for overweight/obese patients and head of bed elevation for nighttime symptoms. 1, 2, 3

First-Line Pharmacological Treatment

PPIs are superior to H2-receptor antagonists and placebo for both healing esophagitis and achieving symptomatic relief. 1, 2 The American Gastroenterological Association establishes PPIs as the most effective first-line treatment for GERD. 1

Specific PPI Dosing

• Omeprazole 20 mg once daily taken 30-60 minutes before breakfast is the standard initial dose. 3, 4
• Lansoprazole 30 mg once daily taken 30-60 minutes before breakfast is an equivalent alternative. 3, 5
• The 30-60 minute pre-meal timing is critical for optimal acid suppression—verify this with patients to ensure compliance. 2, 3
• Initial treatment duration is 4-8 weeks for typical GERD symptoms without alarm features. 1, 2

FDA-Approved Indications

• Omeprazole is FDA-approved for treatment of heartburn and GERD symptoms for up to 4 weeks in patients ≥2 years of age. 4
• For erosive esophagitis, omeprazole is approved for short-term treatment (4-8 weeks), with an additional 4 weeks if needed. 4
• Lansoprazole is similarly approved for symptomatic GERD treatment (up to 8 weeks in adults and adolescents 12-17 years). 5

Essential Lifestyle Modifications

Weight loss has the strongest evidence for efficacy among lifestyle interventions and can prevent or postpone the need for acid suppression. 1, 2 The HUNT study demonstrated a dose-dependent association, with >3.5 unit decrease in BMI showing an odds ratio of 1.98 for loss of reflux symptoms. 2

Specific Lifestyle Recommendations

• Weight reduction is mandatory for all overweight or obese patients (BMI ≥25 kg/m²). 1, 2, 3
• Elevate the head of bed by 6-8 inches (15-20 cm) for patients with nighttime heartburn, regurgitation, or mucous production—this improves esophageal pH profiles. 1, 2, 3
• Avoid lying down for 2-3 hours after meals—this reduces esophageal acid exposure by 30-50%. 1, 2, 3
• Tobacco and alcohol cessation are recommended as both worsen GERD symptoms. 1, 3
• Implement an antireflux diet with fat intake limited to <45g per day, avoiding coffee, tea, soda, chocolate, mints, citrus products, and alcohol. 1, 2

Important Caveat on Dietary Restrictions

Do not broadly recommend all lifestyle modifications to every GERD patient—the American Gastroenterological Association advises against this approach as evidence does not support universal dietary restrictions and it leads to poor compliance. 1 Instead, recommend avoiding specific trigger foods that consistently provoke symptoms in individual patients. 1

Management of Persistent Symptoms

If symptoms persist after 4 weeks of standard once-daily PPI therapy, escalate to twice-daily dosing—one dose before breakfast and one before dinner. 1, 2

Systematic Escalation Algorithm

• First, verify compliance and timing: Ensure the patient is taking PPI 30-60 minutes before meals. 2, 3
• Second, increase to twice-daily PPI dosing if compliance is confirmed. 1, 2, 3
• Third, consider endoscopy after failed empiric therapy to assess for esophagitis or other pathology. 1
• Fourth, for partial response, consider adding H2RAs or alginates to PPI therapy. 2

Common Pitfall to Avoid

The American Gastroenterological Association advises against using doses higher than standard PPI dosing without first optimizing timing and ensuring twice-daily dosing, as evidence for higher doses is weak. 1 Do not add nocturnal H2RA to twice-daily PPI as standard practice—there is no evidence of improved efficacy with this combination. 1

Special Considerations for Extraesophageal Symptoms

For extraesophageal GERD symptoms (chronic cough, laryngitis, asthma), more intensive therapy is required—specifically twice-daily PPI dosing for a minimum of 8-12 weeks. 1, 2

Key Differences in Extraesophageal GERD

• Response rates to PPI therapy are significantly lower for extraesophageal symptoms compared to typical GERD symptoms. 1, 2
• A strict antireflux diet (≤45g fat/day, no coffee, tea, soda, chocolate, mints, citrus, alcohol) is essential. 1
• Allow 1-3 months to assess response before escalating treatment. 1
• Address comorbid conditions that worsen GERD, particularly obstructive sleep apnea. 1
• If cough persists after 3 months of maximal medical therapy, consider 24-hour esophageal pH monitoring. 1

Long-Term Management and Maintenance

After achieving symptom control, titrate to the lowest effective PPI dose to minimize potential long-term risks while maintaining control. 1, 2, 3

Maintenance Strategy

• For patients without erosive disease at baseline, optimize lifestyle modifications and wean to lowest effective PPI dose or on-demand therapy with H2 blockers/antacids. 2
• Periodically reassess the need for continued PPI therapy. 1, 3
• For confirmed erosive esophagitis or Barrett's esophagus, long-term PPI therapy is generally required and benefits outweigh risks. 1, 3

Addressing PPI Safety Concerns

Emphasize the safety of PPIs to patients, as concerns about potential risks (impaired cognition, bacterial gastroenteritis, pneumonia, hip fractures, vitamin B12 deficiency, hypomagnesemia, chronic kidney disease) often lead to poor adherence. 1, 2 While observational studies have suggested these associations, they need confirmation before influencing clinical decision-making. 6

Surgical and Endoscopic Options

Laparoscopic fundoplication is an effective treatment option for young, healthy patients with objectively documented GERD that fails maximal medical therapy for at least 3 months. 1, 2

Surgical Considerations

• The LOTUS trial showed 85% remission at 5 years with laparoscopic fundoplication. 2
• Antireflux surgery improves or cures cough in 85-86% of properly selected patients who failed intensive medical therapy. 1
• Partial fundoplication is preferred in patients with esophageal hypomotility. 2
• Magnetic sphincter augmentation is an option, often combined with crural repair in the setting of hiatal hernia. 2
• Transoral incisionless fundoplication is an endoscopic option for carefully selected patients without hiatal hernia. 2
• Roux-en-Y gastric bypass is effective as a primary anti-reflux intervention in obese patients with GERD. 2

Adjunctive Therapies

Sodium alginate added to PPI therapy results in significantly greater rates of complete heartburn resolution in patients with nonerosive reflux disease (NERD). 2 Alginate-antacid raft formulations localize the postprandial acid pocket and displace it below the diaphragm, reducing post-reflux episodes. 2

Other Adjunctive Options

• Baclofen decreases 24-hour pH scores and acid exposure time, useful as add-on therapy to PPI, but limited by side effects including somnolence, dizziness, weakness, and trembling. 2
• Do not use metoclopramide as monotherapy or adjunctive therapy for GERD due to unfavorable risk-benefit profile, including risk of tardive dyskinesia. 1
• Cognitive behavioral therapy, gut-directed hypnotherapy, or neuromodulators may be beneficial for patients with overlapping functional symptoms. 2

When to Perform Endoscopy

Perform endoscopy in patients with alarm symptoms (dysphagia, weight loss, bleeding), those who fail empiric PPI therapy, or those with risk factors for esophageal adenocarcinoma (older age, male sex, obesity). 1, 6