What are the recommended treatment options for gastroesophageal reflux disease (GERD)?

Treatment of Gastroesophageal Reflux Disease (GERD)

Proton pump inhibitors (PPIs) are the first-line pharmacological treatment for GERD, with omeprazole 20 mg or lansoprazole 30 mg taken 30-60 minutes before breakfast as the initial regimen. 1, 2

Initial Management Approach

Pharmacological Therapy

• Start with omeprazole 20 mg once daily taken 30-60 minutes before breakfast for optimal acid suppression 1, 2, 3
• Alternatively, lansoprazole 30 mg once daily can be used with the same timing 2, 4
• For patients with typical GERD symptoms (heartburn and regurgitation) without alarm features, empiric PPI therapy is appropriate without initial endoscopy 1, 2
• Continue this regimen for 4-8 weeks before assessing response 1, 5

Concurrent Lifestyle Modifications

• Weight loss is the most effective lifestyle intervention for overweight or obese patients (BMI ≥25 kg/m²), with the strongest evidence for reducing GERD symptoms 1, 2
• Elevate the head of the bed by 6-8 inches for patients with nighttime symptoms or regurgitation, as this improves esophageal pH profiles 1, 2
• Avoid lying down for 2-3 hours after meals to reduce esophageal acid exposure by 30-50% 1, 2
• Identify and avoid individual trigger foods (coffee, chocolate, alcohol, spicy foods, citrus, tomatoes) on a case-by-case basis rather than applying blanket dietary restrictions 1
• Limit fat intake to ≤45 grams per day, particularly for patients with bile reflux 1

Treatment Escalation for Persistent Symptoms

Step-Up Approach

• If symptoms persist after 4 weeks of standard once-daily PPI therapy, escalate to twice-daily dosing (one dose before breakfast, one before dinner) 1, 2
• Continue twice-daily PPI for an additional 4-8 weeks before considering further evaluation 1
• After symptom control is achieved, titrate to the lowest effective dose that maintains relief 1, 2

When to Pursue Diagnostic Testing

• Perform upper endoscopy after 8-12 weeks of optimized twice-daily PPI therapy if symptoms persist, to assess for erosive esophagitis, Barrett's esophagus, strictures, or alternative diagnoses 1, 2
• Endoscopy is also indicated for alarm features including dysphagia, unexplained weight loss, anemia, gastrointestinal bleeding, or recurrent vomiting 1
• For patients on long-term PPI therapy (>12 months) without confirmed erosive disease, consider 24-hour esophageal pH monitoring off medication to objectively document GERD before committing to indefinite therapy 1

Management of Refractory GERD

Additional Therapeutic Options

• For persistent symptoms despite twice-daily PPI, implement a strict antireflux diet (≤45g fat/24 hours, eliminate coffee, tea, soda, chocolate, mints, citrus, alcohol) 1
• Consider adding prokinetic therapy for patients with documented delayed gastric emptying, though metoclopramide should be avoided due to risk of tardive dyskinesia 1
• Address comorbid conditions that worsen GERD, such as obstructive sleep apnea 1

Surgical Consideration

• Laparoscopic fundoplication is reserved for carefully selected patients who meet ALL of the following criteria: 1, 2
  • Failed at least 3 months of intensive medical therapy
  • Objective documentation of pathological GERD (erosive esophagitis on endoscopy or abnormal pH monitoring)
  • Significant impairment of quality of life
  • Preserved esophageal peristalsis on manometry
• Surgery shows improvement or cure of symptoms in 85-86% of properly selected patients 1

Special Clinical Scenarios

Extraesophageal GERD Symptoms

• For chronic cough, laryngitis, or asthma suspected to be GERD-related, start with twice-daily PPI from the outset rather than standard once-daily dosing 1
• These symptoms require 8-12 weeks minimum of intensive therapy before assessing response, as they respond less reliably than typical heartburn 1
• Response rates are significantly lower for extraesophageal symptoms compared to typical GERD symptoms 1

Pediatric GERD

• Distinguish physiologic gastroesophageal reflux (GER) from GERD—uncomplicated GER in asymptomatic "happy spitters" requires only conservative management without medication 1
• For infants with suspected GERD, trial a 2-4 week maternal exclusion diet (eliminating milk and egg) in breastfed infants, or extensively hydrolyzed formula in formula-fed infants, as cow's milk protein allergy can mimic GERD 1
• Acid-suppressive therapy in children should be limited to objectively confirmed GERD, not uncomplicated GER 1

Long-Term Management and Safety

Maintenance Therapy

• For confirmed erosive esophagitis or Barrett's esophagus, long-term PPI therapy is generally required and benefits outweigh risks 1, 2
• For patients without confirmed erosive disease, attempt gradual dose reduction or on-demand PPI strategy once symptoms are stable 1
• Periodically reassess the need for continued PPI therapy to minimize potential long-term risks 1, 2

Potential Long-Term Risks

• Chronic PPI therapy carries potential risks including community-acquired pneumonia, Clostridioides difficile infection, bone fractures, vitamin B12 deficiency, hypomagnesemia, and chronic kidney disease 1
• These risks should be weighed against benefits in patients with confirmed GERD, but should not prevent appropriate treatment in those with documented disease 1

Critical Pitfalls to Avoid

• Do not add nocturnal H2-receptor antagonist to twice-daily PPI—no evidence shows added benefit and tachyphylaxis develops within 6 weeks 1
• Do not use metoclopramide routinely due to significant risk of tardive dyskinesia and other extrapyramidal side effects 1
• Do not assume normal endoscopy rules out GERD as the cause of extraesophageal symptoms—pH monitoring may still be needed 1
• Do not continue empiric PPI therapy indefinitely without objective testing if symptoms persist beyond 3 months of optimized therapy 1
• Do not broadly recommend all lifestyle modifications to every patient—focus on weight loss for overweight patients and head-of-bed elevation for nocturnal symptoms, as evidence does not support universal dietary restrictions 1