What is the recommended dose of omeprazole (proton pump inhibitor) for a typical adult patient with Gastroesophageal Reflux Disease (GERD)?

Omeprazole Dosing for GERD

For adults with GERD, start omeprazole 20 mg once daily taken 30-60 minutes before meals for up to 4 weeks. 1, 2, 3

Standard Initial Dosing

• The American College of Gastroenterology and FDA-approved dosing recommend omeprazole 20 mg once daily as the standard initial dose for symptomatic GERD 1, 2, 3
• This dose must be taken 30-60 minutes before meals (not at bedtime) for optimal efficacy, as PPIs require food-stimulated acid secretion to work effectively 1, 2
• The initial treatment duration is up to 4 weeks for symptomatic GERD without erosive esophagitis 1, 3

When to Extend or Escalate Treatment

• If symptoms persist after 4 weeks, extend treatment for an additional 4 weeks at the same 20 mg daily dose before considering dose escalation 1
• For patients with erosive esophagitis, treatment duration extends to 4-8 weeks at 20 mg daily 3
• Only after 4-8 weeks of once-daily therapy should twice-daily dosing be considered if symptoms remain uncontrolled 1, 2

Dose Escalation Considerations

• Twice-daily PPI dosing (omeprazole 20 mg twice daily or 40 mg once daily) may be considered for refractory symptoms, though this is not FDA-approved for routine GERD 2
• For extraesophageal GERD syndromes (such as chronic cough) with typical GERD symptoms, twice-daily dosing for 2-3 months may be warranted, as these conditions require longer treatment duration before improvement 2
• Research demonstrates that 20 mg once daily provides complete symptom resolution in 48% of patients with symptomatic GERD by week 4, compared to only 5% with placebo 4

Maintenance Therapy

• Patients with severe erosive esophagitis (LA grade C/D) require continuous daily maintenance therapy at 20 mg once daily 1, 2
• For patients without erosive esophagitis who achieve symptom control, step down to the lowest effective dose or on-demand therapy 1, 2
• Long-term maintenance dosing should not exceed what is necessary, and all patients require periodic reassessment of their need for continued therapy 1, 2

Critical Pitfalls to Avoid

• Taking omeprazole at bedtime instead of before meals significantly reduces efficacy—this is one of the most common errors in PPI prescribing 1, 2
• Premature dose escalation before allowing adequate time (4-8 weeks) for response at standard dosing 1, 2
• Failure to document the indication for long-term therapy, leading to unnecessary chronic use 2
• Omeprazole requires 3-5 days of daily dosing to reach steady-state acid suppression, so patients should not expect immediate relief 5

Special Populations

• Pediatric patients (2-16 years): 10 mg once daily for weight 10-20 kg; 20 mg once daily for weight ≥20 kg 3
• Hepatic impairment: Consider dose reduction to 10 mg once daily for maintenance therapy 3