Recommended Nexium Dosing for GERD
For a typical adult GERD patient, start with Nexium (esomeprazole) 20 mg once daily taken 30-60 minutes before breakfast for 4-8 weeks, then reassess response. 1, 2
Initial Treatment Approach
Begin with standard single-dose therapy: esomeprazole 20 mg once daily taken 30-60 minutes before a meal (preferably breakfast) for optimal acid suppression. 1, 2, 3
The FDA-approved over-the-counter dose is 20 mg once daily for 14 days, though prescription management typically extends to 4-8 weeks for initial assessment. 3
Reassess symptom response at 4-8 weeks to determine next steps. 1, 2
Dose Escalation for Inadequate Response
If symptoms persist after 4-8 weeks on 20 mg daily:
Increase to esomeprazole 40 mg once daily before breakfast, which provides superior acid suppression compared to other PPIs at standard doses. 1, 2, 4, 5
Alternatively, consider switching to a more potent or extended-release PPI formulation. 1
Twice-daily dosing (20 mg or 40 mg) is NOT FDA-approved but may be considered in refractory cases, though evidence supporting this approach is limited. 1, 2
Maintenance Therapy After Symptom Control
Once symptoms are controlled:
Taper to the lowest effective dose that maintains symptom resolution. 1, 2
For patients with non-erosive GERD or mild disease, attempt on-demand therapy where medication is taken only when symptoms occur. 1, 2
Patients with severe erosive esophagitis (LA grade C/D), Barrett's esophagus, or esophageal strictures require continuous daily maintenance therapy and should not be considered for discontinuation. 2, 6
Critical Timing Considerations
Always take PPIs 30-60 minutes before meals, not at bedtime, for optimal acid suppression. 1, 2, 7
Morning dosing before breakfast provides superior 24-hour and daytime acid control compared to evening dosing. 7
For patients with predominantly nocturnal symptoms, evening dosing before dinner may provide better nighttime acid suppression. 7
Common Pitfalls to Avoid
Do not empirically prescribe twice-daily dosing without first attempting adequate duration (4-8 weeks) of once-daily therapy, as this increases costs and potential complications without strong evidence of benefit. 2
Do not combine PPI with H2-receptor antagonists (like famotidine) as routine therapy; this combination lacks evidence for standard GERD management. 2
Ensure patients understand proper timing (before meals, not at bedtime) as incorrect administration is a common cause of treatment failure. 1, 2
When to Consider Objective Testing
If symptoms do not respond adequately to 4-8 weeks of once-daily PPI followed by dose escalation, perform endoscopy and prolonged wireless pH monitoring off medication to confirm GERD diagnosis. 1
For patients requiring chronic PPI therapy beyond 12 months without confirmed diagnosis, offer objective testing to establish appropriateness of long-term use. 1, 2
Special Populations Requiring Higher Initial Doses
Erosive esophagitis (LA grade B or higher): Start with esomeprazole 40 mg once daily for 8 weeks, then transition to long-term maintenance at the lowest effective dose. 6, 4, 5
Extraesophageal GERD symptoms (chronic cough, laryngitis): May require esomeprazole 40 mg once or twice daily for 2-3 months before symptom improvement occurs. 1, 2