GERD Treatment
Start with a proton pump inhibitor (PPI) as first-line therapy—specifically omeprazole 20 mg or lansoprazole 30 mg once daily, taken 30-60 minutes before breakfast—combined with weight loss if the patient is overweight or obese. 1, 2
Initial Pharmacologic Management
PPIs are superior to H2-receptor antagonists and placebo for both healing esophagitis and achieving symptomatic relief, making them the most effective first-line pharmacological treatment. 1, 2
For patients with typical GERD symptoms (heartburn, regurgitation) without alarm signs (dysphagia, weight loss, anemia, bleeding), begin empiric PPI therapy without initial endoscopy. 1, 2
The standard starting dose is omeprazole 20 mg once daily, taken 30-60 minutes before breakfast to optimally suppress acid production during the meal-stimulated acid secretion phase. 2, 3
Treat for an initial 4-8 week trial period to assess response. 4, 1
Lifestyle Modifications (Evidence-Based Only)
Weight loss is the single most effective lifestyle intervention with proven benefit—recommend this for all patients with BMI ≥25 kg/m², as it improves esophageal pH profiles and can prevent or delay the need for acid suppression. 1, 2, 5
Elevate the head of the bed by 6-8 inches (15-20 cm) for patients with nighttime symptoms or regurgitation, as this improves esophageal pH profiles and acid clearance. 1, 6, 5
Avoid lying down for 2-3 hours after meals, which reduces esophageal acid exposure by 30-50%. 1, 6
Identify and avoid individual trigger foods (coffee, chocolate, alcohol, spicy foods, citrus, tomatoes, fatty foods) only if they consistently provoke symptoms in that specific patient—do not broadly restrict all these foods for every patient. 1, 6
Critical pitfall: Tobacco and alcohol cessation, while generally healthy, have no published evidence of improving GERD symptoms or esophageal pH profiles, so do not emphasize these as GERD-specific interventions. 5
Escalation for Persistent Symptoms
If symptoms persist after 4 weeks of once-daily PPI therapy, escalate to twice-daily dosing (one dose before breakfast, one before dinner) rather than switching to a different PPI or increasing the dose beyond standard. 4, 1, 6
Allow adequate time (4-8 weeks total) on optimized therapy before pursuing diagnostic evaluation. 1, 2
Do not add a nocturnal H2-receptor antagonist to twice-daily PPI therapy, as there is no evidence of improved efficacy with this combination. 1, 6
When to Pursue Diagnostic Testing
Perform upper endoscopy if the patient has:
Consider prolonged wireless pH monitoring (96 hours off medication) if PPI therapy continues beyond 12 months without confirmed GERD to establish appropriate use of long-term therapy. 1
Long-Term Management and De-escalation
After initial symptom control, titrate to the lowest effective PPI dose that maintains symptomatic control. 1, 2
For patients without erosive esophagitis or Barrett's esophagus at baseline, attempt gradual dose reduction or switch to on-demand therapy with H2-blockers/antacids. 4, 1
For patients with confirmed erosive esophagitis (Los Angeles grade B or higher) or Barrett's esophagus, continue PPI therapy indefinitely, as long-term benefits outweigh risks. 4, 1, 6
Periodically reassess the need for continuous PPI therapy to minimize potential long-term risks (impaired cognition, bacterial gastroenteritis, community-acquired pneumonia, hip fractures, vitamin B12 deficiency, hypomagnesemia, chronic kidney disease), though these risks are generally outweighed by benefits in patients with confirmed disease. 1
Special Populations and Refractory Cases
Extraesophageal symptoms (chronic cough, laryngitis, asthma) require more intensive therapy—use twice-daily PPI dosing for a minimum of 8-12 weeks, though response rates are significantly lower than for typical GERD symptoms. 1, 6
For refractory symptoms after 3 months of maximal medical therapy, perform objective diagnostic evaluation with endoscopy and/or 24-hour esophageal pH monitoring before considering surgical options. 2
Laparoscopic fundoplication should be considered for patients with objectively documented GERD who fail maximum medical therapy for at least 3 months, with surgery improving or curing symptoms in 85-86% of properly selected patients. 1, 2
Avoid metoclopramide as monotherapy or adjunctive therapy due to unfavorable risk-benefit profile, including risk of tardive dyskinesia. 1
Patient Education Priorities
Emphasize the safety of PPIs for GERD treatment to address common patient concerns about long-term use. 4
Provide standardized educational materials on GERD mechanisms, weight management strategies, and the brain-gut axis relationship. 4, 1
Develop a shared decision-making care plan that includes therapy selection with explanation of risks/benefits and long-term management strategy including possible de-escalation. 4, 1