First-Line Treatment for Typical GERD Symptoms
A therapeutic trial of a proton pump inhibitor (PPI) is the first-line treatment for patients with typical gastroesophageal reflux disease symptoms (heartburn or regurgitation occurring at least twice weekly). 1, 2
Initial Empirical PPI Therapy
Start with once-daily PPI therapy taken 30-60 minutes before a meal for 4-8 weeks as the initial diagnostic and therapeutic approach for patients presenting with typical heartburn symptoms without alarm features 2, 3
The diagnosis of GERD can be made on clinical grounds based on symptom response to PPI therapy, which has high sensitivity but relatively low specificity 1
This empirical approach is cheaper, less invasive, and more widely available than reflux monitoring with pH or pH/impedance testing 1
Dosing Strategy
If symptoms persist on once-daily PPI, escalate to twice-daily dosing before breakfast and dinner rather than pursuing immediate diagnostic testing 1, 3
A therapeutic trial should consist of twice-daily full-dose PPI for 4 weeks and be regarded as positive if there is at least a 75% reduction in symptom frequency 1
Persistent acid exposure is very uncommon when taking twice-daily PPIs, affecting only around 7% of patients with heartburn or regurgitation 1
When to Screen Before Treatment
Screen for alarm symptoms that mandate immediate endoscopy rather than empirical PPI therapy, including troublesome dysphagia, unintentional weight loss, evidence of gastrointestinal bleeding, persistent vomiting, and palpable mass or lymphadenopathy 2
Patients without alarm features do not require endoscopy or pH monitoring before initiating empirical PPI therapy 1, 2
Adjunctive Lifestyle Modifications
Provide standardized patient education on weight loss (the single most effective lifestyle intervention), head of bed elevation by 6-8 inches, avoiding lying down for 2-3 hours after meals, and individualized trigger food avoidance 2, 3
Weight loss should be recommended for all overweight or obese patients with GERD as it has proven benefit on esophageal pH profiles and symptoms 3
Common Pitfalls to Avoid
Do not perform reflux monitoring with pH or pH/impedance in patients who respond well to PPI therapy unless antireflux surgery is planned 1
Do not add a nocturnal H2-receptor antagonist to twice-daily PPI therapy, as there is no evidence of improved efficacy with this combination 3
Avoid using H2-receptor antagonists as first-line therapy, as PPIs are superior for symptom relief and healing of erosive GERD 3, 4
When Further Evaluation is Needed
Patients who fail to respond adequately to 4-8 weeks of twice-daily PPI therapy warrant diagnostic evaluation with endoscopy and/or pH/impedance monitoring rather than further empirical treatment escalation 1, 2, 3
In patients with inadequate response to twice-daily PPIs, pH/impedance monitoring allows diagnosis of increased acid exposure, association between symptoms and acid or non-acid reflux, and identification of phenotypes including non-erosive reflux disease, hypersensitive esophagus, and functional heartburn 1