Treatment of Gastroesophageal Reflux Disease (GERD)
For adults with typical GERD symptoms (heartburn and regurgitation), start with omeprazole 20 mg once daily taken 30-60 minutes before breakfast for 4-8 weeks, combined with weight loss if overweight/obese and head of bed elevation if nocturnal symptoms are present. 1, 2, 3
Initial Pharmacological Treatment
Proton pump inhibitors (PPIs) are the first-line pharmacological treatment, superior to H2-receptor antagonists and placebo for both healing esophagitis and achieving symptomatic relief 2, 3, 4
Begin with omeprazole 20 mg or lansoprazole 30 mg once daily, taken 30-60 minutes before breakfast to optimally suppress acid production 2, 3
For patients with typical esophageal symptoms (heartburn and regurgitation) without alarm symptoms (dysphagia, weight loss, bleeding), empiric PPI therapy is appropriate without initial endoscopy 1, 2
Essential Lifestyle Modifications
Weight loss should be recommended for all overweight or obese patients (BMI ≥25 kg/m²), as this has the strongest evidence of efficacy and can prevent or delay the need for acid suppression 1, 2, 3
Elevate the head of the bed by 6-8 inches (15-20 cm) for patients with nighttime symptoms or regurgitation when recumbent 1, 2
Avoid lying down for 2-3 hours after meals to reduce esophageal acid exposure by 30-50% 1, 2
Avoid late evening meals and ensure at least 2-3 hours between last meal and bedtime 1, 2
Identify and avoid individual trigger foods (coffee, chocolate, alcohol, spicy foods, citrus, tomatoes) rather than broadly restricting all potential triggers 2, 5
Treatment Escalation for Partial or Non-Responders
If symptoms persist after 4-8 weeks of standard once-daily PPI, increase to twice-daily dosing (one dose before breakfast and one before dinner) 1, 2, 3
Consider switching to a more potent acid suppressive agent if twice-daily dosing is inadequate 1
For patients with persistent symptoms despite optimized PPI therapy, perform upper endoscopy to assess for esophagitis, Barrett's esophagus, or alternative diagnoses 1, 2
Long-Term Management and Titration
After initial symptom control, titrate to the lowest effective dose that maintains symptomatic control 1, 2, 3
For patients who achieve complete symptom resolution, attempt conversion to on-demand therapy if possible 1
Periodically reassess the need for continued PPI therapy to minimize potential long-term risks 1, 2
For confirmed erosive esophagitis (Los Angeles Grade B or higher) or Barrett's esophagus, long-term PPI therapy is generally required and benefits outweigh risks 1, 2
If therapy continues for more than 12 months without confirmed GERD, consider endoscopy with prolonged wireless pH monitoring (96 hours preferred) off medication to establish appropriate use of long-term PPI therapy 1, 2
Special Considerations for Extraesophageal Symptoms
For patients with extraesophageal symptoms (chronic cough, laryngitis, asthma) WITH concurrent typical reflux symptoms, use twice-daily PPI therapy for 8-12 weeks minimum. 1, 2
In patients with chronic cough suspected due to reflux-cough syndrome, treatment should include: (1) diet modification to promote weight loss in overweight/obese patients; (2) head of bed elevation and avoiding meals within 3 hours of bedtime; and (3) in patients who report heartburn and regurgitation, PPIs sufficient to control these symptoms 1
In patients with suspected chronic cough due to reflux-cough syndrome but WITHOUT heartburn or regurgitation, do NOT use PPI therapy alone as it is unlikely to be effective 1
While GI symptoms typically respond within 4-8 weeks, improvement in cough may take up to 3 months 1
Response rates to PPI therapy are significantly lower for extraesophageal symptoms compared to typical GERD symptoms 1, 2
For patients with isolated extraesophageal symptoms without typical reflux symptoms, consider early evaluation by ENT, pulmonary, or allergy specialists to rule out non-GI disorders before extensive reflux testing 1
Medications to Avoid
Do NOT use metoclopramide as monotherapy or adjunctive therapy due to unfavorable risk-benefit profile, including risk of tardive dyskinesia 2, 6
Do NOT add nocturnal H2-receptor antagonist to twice-daily PPI as standard practice, as there is no evidence of improved efficacy and tachyphylaxis develops with continued H2RA use 2
Adjunctive Therapies
Alginate-containing antacids may be used for breakthrough symptoms or as adjunctive therapy when symptoms are only partially responsive to PPIs 1, 2
H2-receptor antagonists (such as famotidine 20 mg twice daily) are less effective than PPIs but more effective than placebo, and may be considered for mild GERD or as an alternative in elderly patients 2, 6, 7
Surgical and Endoscopic Options
Laparoscopic fundoplication should be considered for patients with objectively documented GERD who fail maximum medical therapy for at least 3 months 1, 3
Before considering antireflux surgery, patients should undergo: (1) confirmatory evidence of pathologic GERD; (2) exclusion of achalasia; and (3) assessment of esophageal peristaltic function 1
Magnetic sphincter augmentation and transoral incisionless fundoplication are effective alternatives in carefully selected patients 1
In obese patients with proven GERD, Roux-en-Y gastric bypass is an effective primary anti-reflux intervention, whereas sleeve gastrectomy has potential to worsen GERD 1
Common Pitfalls to Avoid
Do not assume all patients with chronic cough have GERD—use a diagnostic/therapeutic algorithm addressing common causes of cough including cough variant asthma and upper airway cough syndrome 1
Do not continue empiric PPI therapy indefinitely without objective confirmation of GERD, especially in patients with isolated extraesophageal symptoms 1
Do not broadly recommend all lifestyle modifications to every patient—focus on weight loss (if overweight), head of bed elevation (if nocturnal symptoms), and individualized trigger food avoidance 2
Do not use doses higher than standard PPI dosing without first optimizing timing (30-60 minutes before meals) and ensuring twice-daily dosing 2