What is the recommended treatment for gastroesophageal reflux disease (GERD), including lifestyle modifications and pharmacologic therapy?

Treatment of Acid Reflux (GERD)

Start with once-daily proton pump inhibitor (PPI) therapy—omeprazole 20 mg or equivalent—taken 30–60 minutes before breakfast for 4–8 weeks, combined with weight loss if BMI ≥25 kg/m² and head-of-bed elevation for nighttime symptoms. 1

Initial Pharmacologic Management

PPIs are the most effective first-line treatment for GERD, superior to H2-receptor antagonists and antacids for both symptom relief and esophagitis healing. 1, 2

• Take the PPI 30–60 minutes before breakfast on an empty stomach to optimize acid suppression 1
• Continue for 4–8 weeks before assessing response 1
• No endoscopy is needed initially if you have typical heartburn/regurgitation without alarm features (dysphagia, weight loss, anemia, bleeding) 1

Essential Lifestyle Modifications

Weight loss is the single most effective lifestyle intervention—more important than any dietary change—and should be recommended for all patients with BMI ≥25 kg/m². 1, 3

Positional and Timing Changes

• Elevate the head of your bed by 6–8 inches using blocks or a wedge if you have nighttime symptoms 4, 1, 3
• Avoid lying down for 2–3 hours after meals 4, 1, 3
• Sleep in the left lateral decubitus position rather than on your right side 1

Dietary Modifications

• Identify and avoid your individual trigger foods through a detailed dietary history 1, 5
• Common triggers include: coffee, alcohol, chocolate, mint, fatty/fried foods, citrus, tomatoes, carbonated beverages, spicy foods, garlic, and onions 5, 6
• For bile reflux component, limit fat intake to ≤45 grams per day 4, 5
• Avoid eating within 2–3 hours of bedtime 4, 1

Treatment Escalation for Persistent Symptoms

If symptoms continue after 4–8 weeks of standard PPI therapy:

Escalate to twice-daily PPI dosing (one dose before breakfast, one before dinner) for an additional 4–8 weeks. 1, 3

• This is more effective than switching to a different PPI or adding an H2-blocker at night 1, 3
• Do NOT add a nocturnal H2-receptor antagonist to twice-daily PPI—there is no evidence of benefit and tachyphylaxis develops within 6 weeks 1

When to Pursue Endoscopy

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

Endoscopy is also indicated upfront if you have alarm features:

• Dysphagia (difficulty swallowing) 1
• Unexplained weight loss 1
• Gastrointestinal bleeding or anemia 1
• Recurrent vomiting 1
• Hematemesis (vomiting blood) 1

Long-Term Management

After achieving symptom control, taper to the lowest effective PPI dose that maintains relief. 1

• For patients without erosive esophagitis or Barrett's esophagus on endoscopy, consider gradual dose reduction or on-demand therapy 1, 3
• If PPI therapy extends beyond 12 months without objective confirmation of GERD, perform endoscopy with pH monitoring to reassess the need for continued treatment 1
• Patients with confirmed erosive esophagitis or Barrett's esophagus require indefinite PPI therapy 3

Special Considerations for Extraesophageal Symptoms

If you present with atypical symptoms alone (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. 4, 1

• These symptoms require more intensive and prolonged therapy than typical GERD 4, 1
• Response rates are significantly lower for extraesophageal symptoms compared to heartburn 4, 1
• Consider early reflux testing (24-hour pH monitoring) in patients with extraesophageal symptoms alone to confirm GERD before committing to long-term therapy 4

Critical Pitfalls to Avoid

• Do NOT use metoclopramide routinely—it carries significant risk of tardive dyskinesia and other neurologic side effects 1
• Do NOT continue empiric PPI therapy indefinitely without objective testing if symptoms persist beyond 3 months of optimized treatment 4, 1
• Do NOT assume normal endoscopy rules out GERD as the cause of symptoms—pH monitoring may still be needed 1
• Do NOT assess response to extraesophageal symptom treatment too early—allow the full 8–12 weeks before concluding treatment failure 4, 1

Surgical Consideration

Laparoscopic fundoplication is reserved for carefully selected patients who meet ALL of the following criteria:

• Failed at least 3 months of intensive medical therapy 4, 1
• Objective documentation of pathological GERD (erosive esophagitis on endoscopy or abnormal pH monitoring) 4, 1
• Significant impairment of quality of life 4, 1
• Preserved esophageal peristalsis on manometry 1

Surgery improves or cures symptoms in 85–86% of properly selected patients, though effectiveness may decrease over time. 4, 7