Treatment of Gastroesophageal Reflux Disease (GERD)
For a typical adult with GERD, start with an 8-week trial of a standard-dose proton pump inhibitor (PPI) taken 30–60 minutes before breakfast, combined with weight loss if overweight or obese, head-of-bed elevation for nighttime symptoms, and avoiding lying down for 2–3 hours after meals. 1, 2, 3
Initial Pharmacologic Management
PPIs are the most effective first-line pharmacological treatment for GERD, superior to H2-receptor antagonists and antacids for both symptom relief and healing of erosive esophagitis. 1, 3
Begin with omeprazole 20 mg or lansoprazole 30 mg once daily, taken 30–60 minutes before the first meal of the day for 4–8 weeks. 1, 3, 4
Proper timing is critical—PPIs must be taken 30–60 minutes before meals to achieve optimal acid suppression; failure to do so is a common reason for apparent treatment failure. 1, 3
If symptoms persist after 4–8 weeks of standard-dose PPI, escalate to twice-daily dosing (one dose before breakfast, one before dinner) before concluding treatment failure. 1, 2, 3
Essential Lifestyle Modifications
Weight loss is the single most effective lifestyle intervention for overweight or obese patients (BMI ≥25 kg/m²), with strong evidence showing improvement in esophageal pH profiles and symptoms. 1, 2, 3, 5
Elevate the head of the bed by 6–8 inches (not just extra pillows, which can worsen reflux by flexing the neck) for patients with nighttime heartburn or regurgitation. 1, 2, 3, 5
Avoid lying down for 2–3 hours after meals to reduce esophageal acid exposure. 1, 2, 3, 5
Avoid late-evening meals—ensure at least 2–3 hours between the last meal and bedtime. 1
Dietary Modifications
Identify and avoid individual trigger foods through a detailed dietary history rather than applying blanket dietary restrictions to all patients. 1, 2
Common triggers include fatty foods, chocolate, coffee, alcohol, citrus, tomatoes, spicy foods, and carbonated beverages, but these should only be eliminated if they consistently provoke symptoms in the individual patient. 1, 6, 7
Limit fat intake to ≤45 grams per day, particularly for patients with bile reflux or extraesophageal symptoms. 1
Avoid smoking and limit alcohol consumption, as both can worsen GERD symptoms. 1, 7
Management of Persistent Symptoms
After 8–12 weeks of optimized twice-daily PPI therapy, if symptoms persist, perform upper endoscopy to assess for erosive esophagitis, Barrett's esophagus, strictures, or alternative diagnoses. 1, 2, 3
If endoscopy is normal, consider 24-hour esophageal pH monitoring off PPI therapy to objectively confirm GERD before committing to long-term medication. 1, 2
Do not add a nocturnal H2-receptor antagonist to twice-daily PPI as standard practice—evidence does not support improved efficacy, and tachyphylaxis typically develops within 6 weeks. 1
Special Considerations for Extraesophageal Symptoms
For chronic cough, laryngitis, or asthma attributed to GERD, start with twice-daily PPI therapy from the outset rather than standard once-daily dosing. 8, 1
Implement a strict antireflux diet: ≤45g fat per day, complete elimination of coffee, tea, soda, chocolate, mints, citrus products, tomatoes, and alcohol. 8, 1
Allow 8–12 weeks (up to 3 months) for response assessment before concluding treatment failure, as extraesophageal symptoms respond more slowly than typical heartburn. 8, 1, 3
PPIs alone are ineffective for chronic cough without heartburn or regurgitation—lifestyle modifications including diet modification and weight loss are essential components. 8
Long-Term Management
After achieving symptom control, taper PPI to the lowest effective dose that maintains relief to minimize potential long-term risks. 1, 2, 3
Periodically reassess the need for continued PPI therapy, particularly in patients without endoscopically confirmed erosive esophagitis or Barrett's esophagus. 1, 2
Long-term PPI therapy carries potential risks including community-acquired pneumonia, Clostridioides difficile infection, bone fractures, vitamin B12 deficiency, hypomagnesemia, and chronic kidney disease—weigh these against benefits in patients with confirmed GERD. 1
Surgical Consideration
Laparoscopic fundoplication is reserved for carefully selected patients who meet all of the following criteria: failure of at least 3 months of intensive medical therapy, objective documentation of pathological GERD (erosive esophagitis or abnormal pH monitoring), significant quality-of-life impairment, and preserved esophageal peristalsis on manometry. 1
For chronic cough due to GERD, antireflux surgery improves or cures cough in 85–86% of properly selected patients who have failed intensive medical therapy. 8, 1
Critical Pitfalls to Avoid
Do not use metoclopramide routinely for GERD due to its risk of tardive dyskinesia and unfavorable risk-benefit profile. 1, 2
Do not assume normal endoscopy rules out GERD as the cause of extraesophageal symptoms—pH monitoring may still be necessary. 1
Do not assess response to therapy too early for extraesophageal symptoms—allow the full 8–12 weeks before concluding treatment failure. 8, 1
Do not broadly recommend all lifestyle modifications to every patient—evidence does not support this approach and leads to poor compliance; instead, target modifications with the strongest evidence (weight loss, head-of-bed elevation, avoiding recumbency after meals). 1