How should I manage gastro‑esophageal reflux disease in a 59‑year‑old Caribbean man with controlled hypertension and mild chronic kidney disease (reduced glomerular filtration rate and elevated serum creatinine) while avoiding drugs that worsen renal function or interact with his antihypertensive regimen?

Management of GERD in a Patient with Controlled Hypertension and Mild CKD

Start with a standard-dose proton pump inhibitor (PPI) once daily, 30-60 minutes before breakfast, combined with lifestyle modifications—PPIs are safe in mild CKD and do not require dose adjustment at this level of renal function. 1, 2

Initial Pharmacologic Management

Begin omeprazole 20 mg or pantoprazole 40 mg once daily, taken 30-60 minutes before breakfast. 1, 2 PPIs are the most effective first-line treatment for GERD, superior to H2-receptor antagonists (H2RAs) and antacids for both symptom relief and healing esophagitis. 3, 1, 2

Key Considerations for Mild CKD:

• No PPI dose adjustment is needed for mild CKD (elevated creatinine with mildly reduced GFR). 1, 2 PPIs are not significantly renally cleared and are safe in this population.
• If you choose an H2RA instead (though less effective), famotidine requires dose adjustment only when creatinine clearance falls below 60 mL/min. 4 For CrCl 30-60 mL/min, reduce famotidine to 20 mg once daily or 40 mg every other day; for CrCl <30 mL/min, use 20 mg every other day. 4
• Continue ACE inhibitors or ARBs for blood pressure control—these agents are recommended in hypertensive patients with CKD as they provide renoprotection and slow GFR decline. 3 An initial rise in creatinine up to 30% (or even higher with aggressive dual RASI therapy) is expected and acceptable, representing hemodynamic changes rather than kidney injury. 3, 5

Essential Lifestyle Modifications

Implement these evidence-based interventions immediately:

• Weight loss if BMI ≥25 kg/m²—this is the single most effective lifestyle modification with Grade B evidence. 1, 2
• Elevate the head of bed by 6-8 inches for nighttime symptoms or regurgitation. 1, 2
• Avoid lying down for 2-3 hours after meals to reduce esophageal acid exposure. 1, 2
• Limit dietary fat to ≤45 grams per day. 1, 2
• Identify and avoid individual trigger foods (coffee, chocolate, alcohol, spicy foods, citrus, tomatoes) through detailed dietary history. 1, 2

Treatment Escalation Algorithm

After 4-8 Weeks:

• If symptoms persist, increase to twice-daily PPI dosing (one dose before breakfast, one before dinner). 3, 1, 2 This is the appropriate next step rather than switching agents.
• Continue for an additional 4-8 weeks before considering further evaluation. 1, 2

After 8-12 Weeks of Optimized Therapy:

• If symptoms remain troublesome, perform upper endoscopy to evaluate for erosive esophagitis, Barrett's esophagus, stricture, or alternative diagnoses. 3, 1
• Consider 24-hour esophageal pH monitoring (off PPI) if endoscopy is normal but symptoms persist, to confirm GERD diagnosis before long-term therapy. 3, 2

Critical Pitfalls to Avoid

Do not use metoclopramide as monotherapy or adjunctive therapy for GERD—it has an unfavorable risk-benefit profile with risks of tardive dyskinesia, drowsiness, and extrapyramidal reactions. 1, 2 This is particularly important given the patient's CKD, as metoclopramide requires dose reduction in renal impairment.

Do not avoid PPIs due to CKD concerns. While PPIs have been associated with increased risks of community-acquired pneumonia, C. difficile infection, and chronic kidney disease progression in observational studies, these absolute risks are minimal and do not outweigh the benefits of treating symptomatic GERD. 1, 6

Monitor creatinine but do not discontinue ACE inhibitors/ARBs prematurely. An initial creatinine rise up to 30% after starting or intensifying RASI therapy is acceptable and represents beneficial hemodynamic changes. 3, 5 Only discontinue if creatinine rises >30% with standard single-agent RASI therapy, or if hyperkalemia develops. 3

Long-Term Management

• After achieving symptom control, titrate PPI to the lowest effective dose that maintains symptom relief. 3, 1, 2
• For patients without confirmed erosive esophagitis or Barrett's esophagus, consider gradual dose reduction or on-demand therapy once symptoms are controlled. 3, 2
• If continuous PPI therapy extends beyond 12 months without objective GERD confirmation, consider endoscopy or pH monitoring to justify ongoing treatment. 2, 6
• Continue annual monitoring of renal function (eGFR and urinary albumin-to-creatinine ratio) as recommended for all patients with CKD. 3

Drug Interaction Considerations

PPIs do not adversely interact with common antihypertensive medications including ACE inhibitors, ARBs, calcium channel blockers, or diuretics. 1, 2 This makes them ideal for patients with controlled hypertension and mild CKD.

Avoid NSAIDs if erosive esophagitis is documented, as they can worsen mucosal injury and are nephrotoxic in CKD. 2