What first‑line regimen of tegoprazan, itopride, and alginate is recommended for an adult patient with regurgitation‑dominant gastro‑oesophageal reflux disease associated with a hiatal hernia?

Recommended First-Line Regimen for Regurgitation-Dominant GERD with Hiatal Hernia

For an adult with regurgitation-dominant GERD and hiatal hernia, initiate tegoprazan (or another potassium-competitive acid blocker/PPI) once daily 30-60 minutes before breakfast, add alginate 10-20 mL after meals and at bedtime, and consider itopride 100 mg three times daily as adjunctive therapy for regurgitation control. 1, 2

Rationale for This Triple-Therapy Approach

Acid Suppression as Foundation

• Start with tegoprazan (P-CAB) or PPI once daily as the cornerstone therapy, taken 30-60 minutes before breakfast for 4-8 weeks 1, 3
• Hiatal hernia represents a mechanical reflux mechanism that requires robust acid suppression, as large hiatal hernias indicate more severe GERD manifestations 1
• P-CABs like tegoprazan may offer advantages over traditional PPIs in achieving faster and more consistent acid control 4, 5

Alginate as Essential Adjunct for Hiatal Hernia

• Add alginate-containing antacid (10-20 mL) after each meal and at bedtime specifically because guidelines emphasize alginates are "particularly useful for patients with post-prandial and/or nighttime symptoms, and in those with a known hiatal hernia" 1, 2
• Alginates create a protective "raft" that neutralizes the postprandial acid pocket and are especially beneficial when hiatal hernia compromises the anti-reflux barrier 2, 6
• Evidence demonstrates alginate significantly decreases acid reflux events within the first hour after intake in patients with hiatal hernia (6.1 vs 13.7 events with water, P=0.004) 7

Itopride for Regurgitation-Dominant Symptoms

• Consider adding itopride 100 mg three times daily as personalized adjunctive therapy targeting the regurgitation phenotype 1
• While guidelines recommend "prokinetics for coexistent gastroparesis" and note "prokinetics have not been shown to be useful in GERD" generally, itopride specifically has demonstrated efficacy in reducing pathologic reflux 1, 8
• Research shows itopride 100 mg three times daily significantly decreases total percent time with pH<4 and DeMeester score in GERD patients 8
• Important caveat: Guidelines recommend baclofen as first-line for "regurgitation or belch predominant symptoms," though it's "often limited by central nervous system and GI side effects" 1

Treatment Algorithm

Initial 4-8 Week Trial

1. Tegoprazan/P-CAB or PPI once daily before breakfast 1, 3
2. Alginate 10-20 mL after meals (3 times daily) and at bedtime 2, 6
3. Itopride 100 mg three times daily with meals 8
4. Lifestyle modifications: elevate head of bed 6-8 inches, avoid eating 2-3 hours before bedtime, weight loss if overweight 1, 3

Reassessment at 4-8 Weeks

• If adequate response: Continue current regimen and attempt to taper to lowest effective dose over time 1, 3
• If partial response: Increase acid suppression to twice-daily dosing (before breakfast and dinner), continue alginate and itopride 1, 2
• If inadequate response: Consider switching to alternative P-CAB/PPI, evaluate for surgical candidacy given hiatal hernia, or perform pH-impedance monitoring on therapy 1

Critical Considerations and Pitfalls

Long-Term Management

• Patients with hiatal hernia and confirmed GERD typically require indefinite acid suppression therapy at the lowest effective dose that maintains symptom control 1, 3
• Do not discontinue PPI/P-CAB therapy completely in patients with hiatal hernia without objective testing, as they represent more severe GERD manifestations 1

When to Consider Surgery

• Large hiatal hernias with inadequate medical response should prompt evaluation for laparoscopic fundoplication or magnetic sphincter augmentation 1
• Candidacy requires confirmatory evidence of pathologic GERD and assessment of esophageal peristaltic function 1

Monitoring Considerations

• If continuing long-term PPI therapy beyond 12 months without proven GERD, perform endoscopy with prolonged wireless pH monitoring off medication to establish appropriateness 1
• Verify absence of alarm symptoms (dysphagia, weight loss, bleeding) that would necessitate immediate endoscopy 1, 3