From the Guidelines
For recalcitrant GERD despite twice-daily Nexium (esomeprazole), the most effective next step is to optimize the current PPI therapy and consider adding other medications or lifestyle modifications as needed, as recommended by the most recent guidelines 1.
Treatment Options
Several treatment options can be considered for recalcitrant GERD:
- Optimize current PPI therapy by ensuring Nexium is taken 30-60 minutes before meals for maximum effectiveness.
- Adding an H2 receptor antagonist like famotidine 20mg at bedtime can help with nighttime symptoms, as PPIs don't control acid production well during sleep.
- For breakthrough symptoms, consider adding an antacid or alginate preparation like Gaviscon.
- If these measures fail, switching to a different PPI such as dexlansoprazole (Dexilant) 60mg daily might help, as it has a dual-release mechanism providing longer acid suppression.
- Baclofen 5-10mg three times daily can reduce transient lower esophageal sphincter relaxations if regurgitation is prominent.
Lifestyle Modifications
Lifestyle modifications remain crucial:
- Elevate the head of the bed 6-8 inches.
- Avoid eating within 3 hours of bedtime.
- Eliminate trigger foods.
- Lose weight if overweight.
- Stop smoking.
Further Evaluation
If symptoms persist despite these interventions, referral for pH monitoring and impedance testing is warranted to confirm diagnosis and evaluate for surgical options like fundoplication or LINX procedure, as suggested by recent guidelines 1.
Rationale
These approaches work by addressing different aspects of GERD pathophysiology, including acid production, esophageal clearance, and sphincter function, and are supported by the most recent and highest quality evidence 1.
From the FDA Drug Label
In a U.S multi-center, double-blind, active-controlled study, 30 mg of lansoprazole was compared with ranitidine 150 mg twice daily in 151 patients with erosive reflux esophagitis that was poorly responsive to a minimum of 12 weeks of treatment with at least one H 2-receptor antagonist given at the dose indicated for symptom relief or greater, namely, cimetidine 800 mg/day, ranitidine 300 mg/day, famotidine 40 mg/day or nizatidine 300 mg/day. Lansoprazole 30 mg was more effective than ranitidine 150 mg twice daily in healing reflux esophagitis, and the percentage of patients with healing were as follows Table 20: Reflux Esophagitis Healing Rates in Patients Poorly Responsive to Histamine H 2-Receptor Antagonist Therapy Week Lansoprazole 30 mg daily (N=100) Ranitidine 150 mg twice daily (N=51) 4 74.7% * 42.6% 8 83.7% * 32.0% * (p≤0.001) vs ranitidine.
For patients with recalcitrant GERD despite being on Nexium twice a day, lansoprazole 30 mg daily may be a suitable treatment option, as it has been shown to be effective in healing reflux esophagitis in patients who were poorly responsive to H2-receptor antagonists 2.
- Key points:
- Lansoprazole 30 mg daily was more effective than ranitidine 150 mg twice daily in healing reflux esophagitis.
- The study involved patients with erosive reflux esophagitis that was poorly responsive to H2-receptor antagonists.
- Lansoprazole may be useful in patients failing on a histamine H2-receptor antagonist.
From the Research
Treatment Options for Recalcitrant GERD
- Patients with persistent reflux-like symptoms despite being on Nexium twice a day may undergo a diagnostic workup to find objective evidence of GERD through endoscopic and pH-impedance investigations 3.
- Management strategies for refractory GERD include other pharmacologic treatments such as histamine-2 receptor antagonists (H2RAs), alginates, antacids, and mucosal protective agents, potassium competitive acid blockers (PCABs), prokinetics, gamma aminobutyric acid-B (GABA-B) receptor agonists, and metabotropic glutamate receptor-5 (mGluR5) antagonists, and pain modulators 3.
- Invasive antireflux options such as laparoscopic antireflux surgery (LARS), endoscopic transoral incisionless fundoplication (TIF), magnetic sphincter augmentation (LINX), or radiofrequency therapy (Stretta) may be evaluated if there is no benefit from medical therapy, but there is objective evidence of GERD 3.
Diagnostic Strategies
- Endoscopy, ambulatory reflux testing, and oesophageal manometry are suggested diagnostic strategies for refractory reflux-like symptoms (rRLS) 4.
- The role of oesophageal biopsies or the use of reflux-symptom association in patients undergoing reflux testing is not clear 4.
Pharmacologic Treatments
- Increasing the PPI dose in patients who had received 8 weeks of a twice-daily PPI is not suggested 4.
- Adjunctive alginate or antacid therapy may be considered 4.
- The role of adjunctive prokinetics is not clear 4.
- There is little role for adjunctive transient lower oesophageal sphincter relaxation (TLESR) inhibitors or bile acid sequestrants 4.
Invasive Antireflux Options
- Endoscopic or surgical anti-reflux procedures should not be performed in patients with rRLS in the absence of objectively confirmed GERD 4.
- The management of rRLS should be personalized, based on shared decision-making regarding the role of diagnostic testing to confirm or rule out GERD as a basis for treatment optimization 4.