Initial Treatment for GERD
Proton pump inhibitors (PPIs) are the most effective first-line pharmacological treatment for uncomplicated GERD, superior to H2-receptor antagonists and placebo for both symptom relief and esophagitis healing. 1, 2
Pharmacologic Management
Start omeprazole 20 mg (or equivalent: lansoprazole 30 mg, esomeprazole 40 mg, pantoprazole 40 mg) once daily, taken 30–60 minutes before breakfast, for an initial 4–8 week trial. 1, 2, 3, 4 This timing is critical because PPIs work by blocking actively secreting proton pumps, which are most active after meals. 2
For patients with typical symptoms (heartburn, regurgitation) without alarm features (dysphagia, weight loss, anemia, bleeding), empiric PPI therapy is appropriate initial management without endoscopy. 1, 2, 3
If symptoms persist after 4 weeks of standard once-daily dosing, escalate to twice-daily PPI dosing (one dose before breakfast, one before dinner) for an additional 4–8 weeks. 1, 2, 3 Almost all efficacy data come from once-daily studies, but expert consensus unanimously supports twice-daily dosing for inadequate responders. 1
Do not add a nocturnal H2-receptor antagonist to twice-daily PPI therapy—there is no evidence of improved efficacy, and tachyphylaxis develops within 6 weeks. 1, 2
Essential Lifestyle Modifications
Weight loss is the single most effective lifestyle intervention with the strongest evidence base (Grade B recommendation), improving both esophageal pH profiles and symptoms in overweight or obese patients (BMI ≥25 kg/m²). 1, 2, 3 This intervention can prevent or postpone the need for acid suppression. 1, 2
Elevate the head of the bed by 6–8 inches for patients with nighttime heartburn or regurgitation that disturbs sleep—this improves esophageal pH profiles. 1, 2, 3
Avoid lying down for 2–3 hours after meals to reduce esophageal acid exposure. 1, 2, 3
Identify and avoid individual trigger foods through detailed dietary history rather than broadly restricting all potential triggers (coffee, alcohol, chocolate, fatty foods, citrus, carbonated drinks, spicy foods). 1, 2 The problem with universal dietary restrictions is poor compliance; target only foods that consistently provoke symptoms in each patient. 1
When to Escalate or Investigate
If symptoms remain uncontrolled after 8–12 weeks of optimized twice-daily PPI therapy, perform upper endoscopy to assess for erosive esophagitis (Los Angeles grade B or higher), Barrett's esophagus, strictures, eosinophilic esophagitis, or alternative diagnoses. 1, 2, 3
Patients whose heartburn has not adequately responded to twice-daily PPI therapy should be considered treatment failures—this is a reasonable upper limit for empirical therapy before diagnostic testing. 1
Do not continue empiric PPI therapy indefinitely without objective testing if symptoms persist beyond 3 months of optimized treatment. 2, 3
Long-Term Management
Once satisfactory symptom control is achieved, taper to the lowest effective dose that maintains relief. 2, 3
For patients without endoscopically confirmed erosive esophagitis or Barrett's esophagus, consider gradual dose reduction or on-demand PPI strategy once symptoms are stable. 2, 3
If PPI therapy extends beyond 12 months without objective confirmation of GERD, offer endoscopy with prolonged pH monitoring off medication to reassess the need for continued therapy. 2
Therapies to Avoid
Do not use metoclopramide as monotherapy or adjunctive therapy for GERD (Grade D recommendation)—it has an unfavorable risk-benefit profile, including risk of tardive dyskinesia and other extrapyramidal side effects. 1, 2
Special Considerations for Extraesophageal Symptoms
For patients presenting with extraesophageal manifestations (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 symptoms require more intensive and prolonged therapy with lower response rates than typical GERD. 1, 2