In an elderly woman taking pantoprazole 40 mg twice daily who still has gastro‑esophageal reflux despite dietary modifications, what is the next appropriate management?

Management of PPI-Refractory GERD in an Elderly Patient

This patient on pantoprazole 40 mg twice daily with persistent reflux symptoms requires upper endoscopy to evaluate for erosive esophagitis, Barrett's esophagus, or alternative diagnoses, as she has failed an adequate trial of twice-daily PPI therapy. 1

Why Endoscopy is the Next Step

• Patients whose heartburn has not adequately responded to twice-daily PPI therapy should be considered treatment failures, making endoscopy the appropriate next diagnostic step rather than further empirical dose escalation. 1

• The American Gastroenterological Association explicitly recommends endoscopy to evaluate patients with a suspected esophageal GERD syndrome who have not responded to an empirical trial of twice-daily PPI therapy, with biopsies targeting any area of suspected metaplasia, dysplasia, or malignancy. 1

• Twice-daily PPI dosing achieves normalization of esophageal acid exposure in 93-99% of patients, so persistent symptoms despite this regimen strongly suggest either non-acid reflux, functional disorders, or alternative pathology requiring direct visualization. 1, 2

Critical Diagnostic Considerations

• Endoscopy serves multiple purposes in this scenario: identifying erosive esophagitis (which may require continued high-dose therapy), detecting Barrett's esophagus (particularly important in elderly patients), ruling out eosinophilic esophagitis, and excluding malignancy. 1

• If endoscopy reveals normal mucosa, the next step is ambulatory impedance-pH monitoring off PPI therapy (withholding PPI for 7 days) to distinguish true GERD from functional heartburn or reflux hypersensitivity. 1, 2

• Elderly patients are more likely to have severe erosive disease and atypical presentations (dysphagia, weight loss, extraesophageal symptoms) rather than typical heartburn, making objective assessment even more critical. 3

Common Pitfalls to Avoid

• Do not empirically escalate beyond twice-daily PPI dosing without objective testing—there is no evidence supporting higher doses, and this approach delays diagnosis of alternative conditions. 1, 2

• Do not add an H2-receptor antagonist (such as famotidine) to twice-daily PPI therapy, as there is no evidence that combining a nocturnal H2RA with twice-daily PPI improves clinical outcomes. 1

• Ensure the patient is taking pantoprazole correctly: 30-60 minutes before breakfast and dinner, not at bedtime or with meals, as improper timing markedly reduces acid suppression efficacy. 2

If Endoscopy Shows Erosive Esophagitis

• Severe erosive esophagitis (Los Angeles grade C/D) requires continuous daily maintenance therapy and justifies continued twice-daily dosing until healing is confirmed. 2

• After healing is documented, attempt step-down to once-daily pantoprazole 40 mg rather than maintaining twice-daily therapy indefinitely, as higher doses increase costs and have been associated with complications including community-acquired pneumonia and C. difficile infection. 2, 4

If Endoscopy is Normal

• Normal endoscopy with persistent symptoms warrants pH-impedance monitoring to objectively document acid exposure and symptom correlation. 1, 2

• Patients with physiologic acid exposure and negative symptom correlation likely have functional heartburn or reflux hypersensitivity and may benefit from neuromodulators or behavioral therapies rather than continued PPI escalation. 2

• Consider non-acid reflux mechanisms (bile, pepsin) that may not respond to acid suppression alone, which can be identified through impedance monitoring. 1

Addressing Dietary Modifications

• While the patient has made dietary changes, ensure comprehensive lifestyle modifications including: no more than 45 g fat per 24 hours, avoiding coffee, tea, soda, chocolate, mints, citrus (including tomatoes), alcohol, smoking cessation, avoiding eating within 2 hours of bedtime, and head-of-bed elevation. 1

• Weight loss of >5-10 pounds has been shown to correlate with symptom improvement independent of medication, making this a critical adjunctive intervention in elderly patients. 1

Timeline Considerations

• Do not delay endoscopy beyond 8 weeks after establishing optimized twice-daily PPI therapy in this elderly patient, to ensure timely exclusion of serious pathology including malignancy. 2

• If the patient has been on this regimen for less than 4-8 weeks, complete the full trial period before proceeding to endoscopy, as some patients require the full duration to respond. 1, 2