What is the recommended management for a patient with typical gastro‑oesophageal reflux disease seeking symptomatic relief?

Recommended Management for Symptomatic GERD Relief

For patients with typical GERD symptoms (heartburn, regurgitation) without alarm features, initiate a 4–8 week trial of single-dose proton pump inhibitor (PPI) therapy taken 30–60 minutes before breakfast, combined with targeted lifestyle modifications including weight loss if overweight and head-of-bed elevation for nocturnal symptoms. 1

Initial Pharmacologic Approach

• Start with any commercially available PPI (omeprazole 20 mg, lansoprazole 30 mg, esomeprazole 40 mg, or pantoprazole 40 mg) once daily, 30–60 minutes before the first meal of the day 1, 2
• PPIs are the most effective first-line pharmacological treatment for GERD, demonstrating superior efficacy over H2-receptor antagonists and antacids for both symptom relief and esophagitis healing 3, 4
• No endoscopy is required initially for patients presenting with typical symptoms and no alarm features (dysphagia, weight loss, anemia, bleeding, or recurrent vomiting) 1, 4
• Provide patient education emphasizing PPI safety to address common concerns about long-term use 1

Essential Lifestyle Modifications

• Weight loss is mandatory for all overweight or obese patients (BMI ≥25 kg/m²), as this is the single lifestyle intervention with the strongest evidence for reducing GERD symptoms and improving esophageal pH profiles 1, 3, 5
• Elevate the head of the bed by 6–8 inches (15–20 cm) using blocks or a wedge for patients with nighttime symptoms or regurgitation when lying down 1, 3, 5
• Avoid lying down for 2–3 hours after meals to reduce esophageal acid exposure 1, 3, 4
• Identify and eliminate individual trigger foods through detailed dietary history rather than applying blanket dietary restrictions—common triggers include coffee, chocolate, alcohol, spicy foods, citrus, and high-fat meals 1, 3

Treatment Escalation for Inadequate Response

• After 4–8 weeks, reassess symptom control 1
• If symptoms persist despite adherence, escalate to twice-daily PPI dosing (one dose 30–60 minutes before breakfast, one before dinner) for an additional 4–8 weeks 1, 3, 4
• Alternatively, switch to a more potent PPI (rabeprazole, esomeprazole) or one with extended-release formulation (dexlansoprazole) 1
• Do not add nocturnal H2-receptor antagonists to twice-daily PPI therapy, as evidence does not support added benefit and tachyphylaxis develops within 6 weeks 3

Adjunctive Therapies for Breakthrough Symptoms

• Alginate-containing antacids (e.g., Gaviscon 10–20 mL after meals and at bedtime) provide rapid relief for breakthrough symptoms, post-prandial symptoms, and nighttime symptoms by creating a protective "raft" that neutralizes the acid pocket 3, 6
• Antacids alone can be used for occasional, mild breakthrough symptoms requiring rapid relief 3, 4

When to Pursue Diagnostic Testing

• Perform upper endoscopy if symptoms persist after 8–12 weeks of optimized twice-daily PPI therapy to assess for erosive esophagitis (Los Angeles grade B or higher), Barrett's esophagus, strictures, or alternative diagnoses 1, 3, 4
• Endoscopy is also indicated upfront if alarm symptoms are present (dysphagia, unexplained weight loss, anemia, gastrointestinal bleeding, recurrent vomiting, or hematemesis) 1, 3
• If endoscopy is normal but symptoms persist, perform 96-hour wireless pH monitoring off PPI (withhold PPI for 2–4 weeks before testing) to confirm GERD diagnosis and phenotype 1, 3

Long-Term Management and De-Escalation

• Once adequate symptom control is achieved, taper PPI to the lowest effective dose that maintains relief 1, 3, 4
• For patients without endoscopically confirmed erosive esophagitis or Barrett's esophagus, consider gradual dose reduction or on-demand PPI strategy once symptoms are stable 3, 4
• If PPI therapy continues beyond 12 months without objective GERD confirmation, offer endoscopy with prolonged pH monitoring to establish appropriateness of long-term therapy 1
• Routine re-evaluation of treatment should be performed within 12 months of PPI initiation for unproven GERD 1

Critical Pitfalls to Avoid

• Do not use metoclopramide as monotherapy or adjunctive therapy for GERD due to unfavorable risk-benefit profile, including risk of tardive dyskinesia 3, 4
• Do not broadly recommend all lifestyle modifications to every patient, as evidence does not support this approach and leads to poor compliance—target only those with proven benefit (weight loss, head-of-bed elevation, avoiding recumbency after meals) 3
• Do not continue empiric PPI therapy indefinitely without objective testing if symptoms persist beyond 3 months of optimized therapy 1, 3
• Do not assess treatment response too early—allow the full 4–8 week trial before concluding treatment failure 1

Special Considerations for Extra-Esophageal Symptoms

• For isolated extra-esophageal symptoms (chronic cough, laryngitis, globus sensation, asthma) without typical heartburn, start with twice-daily PPI dosing from the outset and continue for a minimum of 8–12 weeks before assessing response, as these manifestations require more intensive therapy and have lower response rates 1, 3, 4
• Perform objective reflux testing upfront (rather than empiric PPI trial) in patients with isolated extra-esophageal symptoms to confirm reflux etiology 1