Initial Medication for GERD
Proton pump inhibitors (PPIs) are the recommended first-line medication for GERD, as they are more effective than H2-receptor antagonists (H2RAs) for both symptom relief and healing of erosive esophagitis. 1
First-Line Treatment Approach
Start with once-daily PPI therapy (such as omeprazole 20 mg or lansoprazole 30 mg) taken 30-60 minutes before the first meal of the day for patients with typical GERD symptoms (heartburn, regurgitation) 2, 3, 4
PPIs provide superior healing rates compared to H2RAs: at 8 weeks, PPIs achieve 81-91% healing versus 49-63% with H2RAs 5
Symptom relief occurs more rapidly with PPIs, with 77-81% of patients experiencing heartburn relief at 4 weeks compared to 46-47% with H2RAs 5
Treatment Duration and Escalation
Initial empiric therapy should last 4-8 weeks for typical GERD symptoms without alarm features 1, 6
If symptoms persist after 4-8 weeks of once-daily PPI, escalate to twice-daily dosing (taken before breakfast and dinner) rather than switching to a different medication 1
Patients who fail to respond to twice-daily PPI therapy should be considered treatment failures and require diagnostic evaluation with endoscopy 1
Why PPIs Over H2-Receptor Antagonists
H2RAs (like famotidine) develop tachyphylaxis within 6 weeks, limiting long-term effectiveness 7
The American Gastroenterological Association explicitly states that PPIs are more effective than H2RAs for healing esophagitis and symptom relief 1, 7
H2RAs should be reserved for adjunctive use (such as breakthrough nocturnal symptoms in patients already on PPIs), not as primary monotherapy 7
Common Pitfalls to Avoid
Do not use metoclopramide as monotherapy or adjunctive therapy—it is explicitly recommended against (Grade D) 1
Do not add a nocturnal H2RA to twice-daily PPI therapy—there is no evidence supporting improved efficacy with this combination 1, 7
Do not use higher than standard PPI doses initially—data supporting higher-than-standard doses are weak 1
Ensure proper timing: PPIs should be taken 30-60 minutes before meals for optimal acid suppression, not at bedtime 2, 3
When to Perform Endoscopy Before Treatment
Patients with alarm symptoms: dysphagia, weight loss, bleeding, or anemia require endoscopy before empiric therapy 1, 4
Older patients with risk factors for esophageal adenocarcinoma (male sex, obesity, chronic symptoms) should undergo endoscopy 4
Otherwise, endoscopy is not necessary before starting empiric PPI therapy in patients with typical GERD symptoms 1, 4
Long-Term Management Considerations
After initial symptom control, attempt step-down therapy to the lowest effective PPI dose 1, 6
Most patients with GERD severe enough to warrant initial PPI therapy will require chronic maintenance therapy 1
On-demand PPI therapy is an acceptable maintenance strategy for select patients with milder disease 6
The risks of long-term PPI use (including potential for C. difficile infection and decreased calcium absorption) are generally minimal and do not warrant routine precautionary testing such as bone density studies or calcium supplementation 1