Managing Heartburn: A Practical Approach
Start with a 4-8 week trial of a proton pump inhibitor (PPI) taken 30-60 minutes before breakfast, combined with weight loss if overweight and head-of-bed elevation for nighttime symptoms. 1
Initial Treatment Strategy
First-Line Pharmacotherapy
Begin with omeprazole 20 mg (or equivalent PPI) once daily, taken 30-60 minutes before breakfast. 1 This timing is critical because PPIs work best when proton pumps are actively secreting acid after a meal. 2
- PPIs are superior to H2-receptor antagonists and antacids for both symptom relief and healing of erosive esophagitis. 2, 3, 4
- Emphasize to patients that PPIs are safe for long-term use when GERD is confirmed—the benefits outweigh potential risks in patients with documented disease. 1
- No endoscopy is needed initially for typical heartburn without alarm symptoms (dysphagia, weight loss, anemia, bleeding). 1, 2
Essential Lifestyle Modifications
Weight loss is the single most effective lifestyle intervention (Grade B evidence) for patients with BMI ≥25 kg/m². 1, 2, 5 A reduction of >3.5 BMI units roughly doubles the odds of symptom resolution. 2
For nighttime symptoms, elevate the head of the bed by 6-8 inches using blocks or a wedge—not just pillows. 1, 2, 5 This improves esophageal acid clearance and reduces nocturnal reflux episodes. 6, 5
Avoid lying down for 2-3 hours after meals to reduce esophageal acid exposure. 1, 2, 5
Identify individual trigger foods through detailed dietary history rather than imposing blanket restrictions. 1, 2, 5 Common triggers include coffee, chocolate, alcohol, fatty foods, spicy foods, citrus, and tomatoes. 2, 5
Treatment Escalation Algorithm
Step 1: Reassess After 4 Weeks
If symptoms persist after 4 weeks of once-daily PPI:
Escalate to twice-daily PPI dosing—one dose 30-60 minutes before breakfast, another before dinner. 1, 2, 5 Continue for an additional 4-8 weeks. 1
Do NOT add a nighttime H2-receptor antagonist to twice-daily PPI—there is no evidence of added benefit, and tachyphylaxis develops within 6 weeks. 1, 2, 5
Step 2: Endoscopy After 8-12 Weeks of Optimized Therapy
If symptoms remain uncontrolled after 8-12 weeks of twice-daily PPI plus lifestyle measures, perform upper endoscopy. 1, 6, 2, 5 This is the upper limit for empiric therapy. 2
The endoscopy should assess for:
- Erosive esophagitis (graded by Los Angeles classification) 1
- Barrett's esophagus (graded by Prague classification with biopsies) 1, 6
- Strictures 1, 6
- Eosinophilic esophagitis (requires ≥5 biopsies) 6
- Hiatal hernia (Hill grade) 1
Step 3: pH Monitoring if Endoscopy is Normal
If endoscopy is normal but symptoms persist, perform 96-hour wireless pH monitoring OFF PPI (withhold therapy for 2-4 weeks). 1, 2 This confirms GERD diagnosis and differentiates true reflux disease from functional heartburn or esophageal hypersensitivity. 1, 7
When to Refer for Endoscopy Immediately
Perform endoscopy upfront (without empiric PPI trial) in patients with:
- Alarm symptoms: dysphagia, unexplained weight loss, anemia, GI bleeding, recurrent vomiting 1, 6, 2
- Long-standing GERD with new dysphagia—urgent evaluation needed to rule out esophageal adenocarcinoma, stricture, or eosinophilic esophagitis 6
- Isolated extra-esophageal symptoms (chronic cough, laryngitis, globus) without typical heartburn—objective testing is preferred over empiric therapy 1, 2
- Family history of gastric cancer in ≥1 first-degree relative, especially with persistent symptoms 2
Special Considerations
Extra-Esophageal Symptoms (Chronic Cough, Laryngitis, Globus)
Start with twice-daily PPI from the outset and continue for a minimum of 8-12 weeks before assessing response. 1, 2 These manifestations require more intensive therapy and have lower response rates than typical heartburn. 1, 2
Add a strict anti-reflux diet: limit fat to ≤45g/day, eliminate coffee, tea, soda, chocolate, mints, citrus, and alcohol. 2
Long-Term Management
Once symptoms are controlled, taper PPI to the lowest effective dose. 1, 2, 5
For patients without erosive esophagitis or Barrett's esophagus on endoscopy, consider gradual dose reduction or on-demand therapy. 1, 2
If PPI therapy continues beyond 12 months without objective confirmation of GERD, offer endoscopy with prolonged pH monitoring to justify long-term use. 1
Critical Pitfalls to Avoid
Do NOT use metoclopramide as monotherapy or adjunctive therapy for GERD—the risk of tardive dyskinesia and extrapyramidal effects outweighs any benefit. 1, 2
Do NOT continue empiric PPI therapy indefinitely without objective testing if symptoms persist beyond 3 months of optimized treatment. 1, 2
Do NOT ignore dysphagia—it always requires endoscopic evaluation in patients with long-standing GERD to rule out malignancy. 6
Do NOT recommend all lifestyle modifications en bloc—individualize based on the patient's specific triggers to improve compliance. 6, 2
Do NOT use higher-than-standard PPI doses without first optimizing timing and ensuring twice-daily dosing. 2
Adjunctive Therapies (Personalized to Phenotype)
Alginate antacids (e.g., Gaviscon) for breakthrough post-prandial symptoms 1, 2
Baclofen (5-10 mg three times daily, titrated to 20 mg three times daily) for regurgitation-predominant symptoms 1, 2
Low-dose tricyclic antidepressants (amitriptyline or nortriptyline 10-25 mg at bedtime) for esophageal hypersensitivity confirmed on pH-impedance testing 1, 2
Surgical Referral Criteria
Anti-reflux surgery is appropriate ONLY when ALL of the following are met:
- Failure of ≥3 months of intensive medical therapy (twice-daily PPI + lifestyle measures) 1, 2
- Objective documentation of pathological GERD (erosive esophagitis on endoscopy OR abnormal pH monitoring off PPI) 1, 2
- Positive symptom-reflux correlation on pH-impedance testing 2
- Preserved esophageal peristalsis on high-resolution manometry 1, 2
- Significant quality-of-life impairment 1, 2
Laparoscopic fundoplication yields 85% remission at 5 years in properly selected patients. 2