I have gastro‑oesophageal reflux disease, tried omeprazole 20 mg twice daily with no benefit and dexlansoprazole (Dexilant) 60 mg with better symptom control; what is the appropriate next step in management?

Continue Dexlansoprazole 60 mg Daily

You should continue dexlansoprazole 60 mg once daily, as it has already demonstrated superior symptom control compared to omeprazole 20 mg twice daily, and switching back to omeprazole or escalating it further is not supported by evidence when a more effective PPI has been identified. 1

Why Dexlansoprazole is the Appropriate Choice

Superior Acid Suppression Profile

• Dexlansoprazole's dual delayed-release formulation provides two distinct drug releases (at 1-2 hours and 4-5 hours post-dose), resulting in the longest maintenance of plasma concentration among all PPIs and prolonged acid suppression throughout the 24-hour period 2, 3
• This extended acid control is particularly beneficial for patients who failed standard PPI therapy, as it addresses both daytime and nighttime acid breakthrough 2

Evidence Supporting Your Clinical Response

• In head-to-head trials, dexlansoprazole 60 mg demonstrated comparable healing rates to lansoprazole 30 mg for erosive esophagitis, with no significant differences in efficacy 3, 4
• A 24-week randomized trial showed that dexlansoprazole resulted in fewer days with reflux symptoms compared to esomeprazole 40 mg (37.3 vs 53.9 days; P=0.008), with better persistent symptom improvement during maintenance therapy 5
• Your clinical response to dexlansoprazole after failing omeprazole 20 mg BID suggests you are among the subset of patients who require more sustained acid suppression 5

Why Not Return to Omeprazole

Omeprazole Has Already Failed

• You completed an adequate trial of omeprazole 20 mg twice daily without significant benefit, which represents the appropriate escalation from once-daily dosing 1
• Twice-daily PPI dosing achieves acid normalization in 93-99% of patients; your lack of response indicates either inadequate acid suppression with omeprazole specifically or a need for the prolonged pharmacokinetic profile that dexlansoprazole provides 1

No Evidence for Further Omeprazole Escalation

• Escalating omeprazole beyond 20 mg twice daily is not FDA-approved and lacks supporting evidence 1
• Guidelines explicitly state that double-dose PPIs have not been studied in randomized controlled trials and should not be used 1

Recommended Management Algorithm

Immediate Next Steps (Weeks 1-8)

• Continue dexlansoprazole 60 mg once daily for a full 8-week course to assess complete therapeutic response 6
• Take the medication without regard to food (unlike traditional PPIs, dexlansoprazole does not require pre-meal timing) 6, 2
• Monitor symptom frequency using a diary to document heartburn-free days 7

Assessment at 8 Weeks

• If you achieve complete symptom resolution (≥75% reduction in reflux symptoms), proceed to maintenance therapy 1
• If symptoms persist despite 8 weeks of dexlansoprazole 60 mg, you meet criteria for treatment failure and should undergo upper endoscopy to exclude erosive esophagitis, Barrett's esophagus, or alternative diagnoses 1

Maintenance Strategy (After 8 Weeks of Symptom Control)

• Step down to dexlansoprazole 30 mg once daily for maintenance therapy, as this is the FDA-approved maintenance dose 6
• Continue maintenance therapy for up to 6 months with periodic reassessment 6
• If you have non-erosive GERD (confirmed by endoscopy), consider transitioning to on-demand therapy after several months of stable control on 30 mg daily 1

Critical Pitfalls to Avoid

Do Not Switch PPIs Prematurely

• Switching between PPIs without completing an adequate trial (8 weeks) is a common error that delays appropriate diagnosis and management 8
• Since dexlansoprazole is already providing better symptom control, switching back to omeprazole would be counterproductive 5

Do Not Add H2-Receptor Antagonists

• Adding famotidine or other H2RAs to dexlansoprazole has no proven benefit and is not evidence-based for routine GERD management 1
• The combination of PPI + H2RA should only be considered for documented nocturnal breakthrough symptoms despite adequate PPI therapy 1

Ensure Proper Lifestyle Modifications

• Limit total daily fat intake to ≤45 g, avoid coffee, tea, soda, chocolate, mint, citrus (including tomatoes), and alcohol 1
• Refrain from eating within 2 hours of bedtime and elevate the head of the bed 1
• Weight loss of >5-10 lb has been associated with symptom improvement independent of medication 1

When to Pursue Further Evaluation

Indications for Endoscopy

• Persistent symptoms after completing 8 weeks of dexlansoprazole 60 mg daily 1
• Development of alarm symptoms: dysphagia, bleeding, anemia, unintentional weight loss, or recurrent vomiting 8
• Age ≥71 years with new-onset GERD symptoms (to exclude Barrett's esophagus or malignancy) 1

If Endoscopy Shows Normal Mucosa

• Perform ambulatory pH-impedance monitoring off PPI therapy (after 7-day washout) to differentiate true GERD from functional heartburn or reflux hypersensitivity 1
• This testing objectively documents acid exposure and symptom correlation, guiding further management 1

Long-Term Considerations

Periodic Reassessment

• All patients on long-term PPI therapy should have their indication clearly documented and periodically reassessed 1
• In patients ≥65 years, PPIs are classified as potentially inappropriate medications when used >12 weeks without a clear evidence-based indication 1

Monitoring for Adverse Effects

• Long-term PPI use is associated with increased risk of Clostridioides difficile infection and community-acquired pneumonia in older adults 1
• Consider periodic serum magnesium assessment, as chronic PPI use can lead to hypomagnesemia 1