Primary Management for GERD
Proton pump inhibitors (PPIs) taken 30–60 minutes before breakfast are the cornerstone of GERD management, combined with weight loss for overweight patients and head-of-bed elevation for nocturnal symptoms. 1, 2
Initial Pharmacologic Approach
- Start with a single daily dose of any standard PPI (omeprazole 20 mg, lansoprazole 30 mg, esomeprazole 40 mg, or pantoprazole 40 mg) taken 30–60 minutes before breakfast for 4–8 weeks 1, 2, 3, 4, 5
- Endoscopy is not required initially for patients with typical heartburn or regurgitation who lack alarm symptoms (dysphagia, weight loss, anemia, bleeding) 1, 2
- PPIs are superior to H2-receptor antagonists for both healing erosive esophagitis and achieving symptomatic relief 1, 2, 6
Essential Lifestyle Modifications
Weight loss is the single most effective lifestyle intervention and should be recommended for all patients with BMI ≥25 kg/m² 7, 1, 2, 8:
- A decrease of >3.5 BMI units roughly doubles the odds of symptom resolution 7
- Weight loss improves esophageal pH profiles and reduces symptoms 8
Head-of-bed elevation by 6–8 inches (using blocks or a wedge) for patients with nighttime reflux or regurgitation 7, 1, 2, 8:
- This improves esophageal pH profiles and is supported by evidence-level B 8
Avoid lying down for 2–3 hours after meals to reduce esophageal acid exposure 7, 1, 2
Identify and eliminate individual trigger foods through detailed dietary history (common triggers: coffee, chocolate, alcohol, spicy foods, citrus, high-fat meals) 1, 2:
- Broad dietary restrictions for all patients are not evidence-based and lead to poor compliance 2
- Only recommend avoiding foods that consistently provoke symptoms in that specific patient 1, 2
Treatment Escalation for Persistent Symptoms
If symptoms persist after 4 weeks of standard once-daily PPI therapy 1, 2:
- Escalate to twice-daily PPI dosing (one dose 30–60 minutes before breakfast, second dose before dinner) for an additional 4–8 weeks 1, 2, 6
- Twice-daily dosing provides superior gastric acid suppression 2, 6
When to Perform Endoscopy
Perform upper endoscopy after 8–12 weeks of optimized twice-daily PPI therapy if symptoms remain uncontrolled, to assess for 1, 2:
- Erosive esophagitis (Los Angeles grade B or higher)
- Barrett's esophagus
- Strictures
- Alternative diagnoses (eosinophilic esophagitis, malignancy)
Endoscopy is indicated upfront when alarm features are present (dysphagia, weight loss, anemia, bleeding, recurrent vomiting) 1, 2
Long-Term Management
- After achieving symptom control, taper to the lowest effective PPI dose that maintains relief 1, 2, 6
- For patients without endoscopically confirmed erosive esophagitis or Barrett's, consider gradual dose reduction or on-demand PPI strategy once symptoms are stable 1, 2
- Periodically reassess the need for continued PPI therapy to minimize potential long-term risks (vitamin B12 deficiency, hypomagnesemia, bone fractures, chronic kidney disease) 1, 2
Special Considerations for Pediatric Patients
- Distinguish physiologic gastroesophageal reflux (GER) from GERD in children; uncomplicated GER in asymptomatic "happy spitters" requires only conservative management without medication 7, 1
- Lifestyle changes are first-line therapy for both GER and GERD in pediatric patients 7
- Medications are indicated only for patients with confirmed GERD (reflux associated with troublesome symptoms or complications) 7, 1
Critical Pitfalls to Avoid
- Do not continue empiric PPI therapy indefinitely without objective testing when symptoms persist beyond 3 months of optimized treatment 1, 2
- Do not add nocturnal H2-receptor antagonist to twice-daily PPI; evidence shows no added benefit and tachyphylaxis develops within 6 weeks 2
- Do not use metoclopramide routinely for GERD due to unfavorable risk-benefit profile, including risk of tardive dyskinesia 7, 2
- Do not broadly recommend all lifestyle modifications to every patient; focus on weight loss (if BMI ≥25) and head-of-bed elevation (if nocturnal symptoms), as these have the strongest evidence 2, 8