From the Guidelines
Elderly patients with acid reflux should start with lifestyle modifications and a 4- to 8-week trial of single-dose proton pump inhibitors (PPIs) as the initial treatment approach, as recommended by the most recent guidelines 1. This approach is based on the latest evidence from the American Gastroenterological Association (AGA) clinical practice update on the personalized approach to the evaluation and management of GERD, which suggests that a stepwise diagnostic approach and a precision management plan can help identify the underlying mechanisms driving symptoms and improve treatment outcomes 1. The treatment plan should include:
- Lifestyle modifications such as avoiding trigger foods, eating smaller meals, and not lying down for 2-3 hours after eating
- Weight loss if overweight and elevating the head of the bed 6-8 inches
- A 4- to 8-week trial of single-dose PPIs, with escalation to twice-a-day dosing or switching to a more potent acid suppressive agent if symptoms persist
- Symptom response should prompt PPI titration to the lowest effective dose
- Objective reflux testing should be offered to establish a diagnosis of GERD and a long-term management plan when long-term PPI therapy is planned Other studies, such as the 2016 Chest guideline and expert panel report, also recommend diet modification, head of bed elevation, and avoiding meals within 3 hours of bedtime, as well as PPIs, H2-receptor antagonists, alginate, or antacid therapy sufficient to control symptoms 1. However, the 2022 AGA clinical practice update provides the most recent and highest-quality evidence, and its recommendations should be prioritized in clinical practice 1.
From the FDA Drug Label
1.4 Treatment of Symptomatic Gastroesophageal Reflux Disease (GERD) Omeprazole delayed-release capsules are indicated for the treatment of heartburn and other symptoms associated with GERD for up to 4 weeks in patients 2 years of age and older. 1.7 Treatment of Symptomatic Gastroesophageal Reflux Disease (GERD) Lansoprazole delayed-release capsules are indicated for short-term treatment in adults and pediatric patients 12 to 17 years of age (up to eight weeks) and pediatric patients one to 11 years of age (up to 12 weeks) for the treatment of heartburn and other symptoms associated with GERD
Treatment for acid reflux in the elderly can be managed with omeprazole or lansoprazole.
- Omeprazole is indicated for the treatment of heartburn and other symptoms associated with GERD for up to 4 weeks in patients 2 years of age and older 2.
- Lansoprazole is indicated for short-term treatment in adults for the treatment of heartburn and other symptoms associated with GERD 3. However, there is no specific information regarding the elderly population in the provided drug labels.
From the Research
Treatment Options for Acid Reflux in the Elderly
- Proton pump inhibitors (PPIs) are considered the first-line therapeutic drug for the treatment of reflux esophagitis due to their potent and long-lasting acid inhibition, especially during the daytime when gastro-esophageal refluxes frequently occur 4.
- Histamine H2 receptor antagonists (H2RA) can be used as a supplementary drug for patients with nocturnal refluxes, as their acid inhibitory effect is more potent during the nocturnal period, but becomes attenuated after 2-week-long oral administration due to tolerance phenomenon 4.
- Combination therapy with PPIs and H2RA may be considered for patients who still experience nocturnal acid breakthrough despite taking PPIs twice daily, although the clinical significance of this approach is not clear 5, 6.
Lifestyle Modifications for Acid Reflux in the Elderly
- Lifestyle modifications, such as education on health behaviors and promotion of healthy habits, can play an instrumental role in the prevention and management of GERD in older adults 7.
- Registered nurses can serve as patient advocates and provide education on GERD management, addressing the gap in multilingual and culturally relevant content 7.
Considerations for Older Patients with Acid Reflux
- Older patients with GERD may have fewer symptoms, but their disease is more often severe and can lead to potentially life-threatening complications, such as esophageal and extraesophageal complications 8.
- A more aggressive approach may be warranted in elderly patients due to the higher incidence of severe complications, and specific issues of causation, evaluation, and treatment must be considered when dealing with older adults 8.