Management of Gastroesophageal Reflux Disease

Introduction to Prokinetics

The American Gastroenterological Association recommends against the use of metoclopramida as monotherapy or adjuvant empirical therapy in patients with gastroesophageal reflux disease (Grade D) 1
The American Gastroenterological Association establishes that prokinetics should be personalized to the specific phenotype of gastroesophageal reflux disease, not used empirically 2

The American Gastroenterological Association recommends that prokinetics be considered only in specific situations, such as regurgitation or eructation predominant symptoms, where baclofen (a GABA-B agonist) may be considered 2
Prokinetics are indicated only when delayed gastric emptying is documented through a gastric emptying study, in cases of coexisting gastroparesis 2

The American Gastroenterological Association recommends optimizing proton pump inhibitor therapy by increasing the dose to twice a day if the patient is taking it once a day, and verifying the timing of administration (30-60 minutes before meals) 1, 3, 4
Patients who do not respond to proton pump inhibitors twice a day should be considered therapeutic failures 1, 3
Endoscopy is indicated when there is no adequate response to proton pump inhibitors twice a day, to look for erosive esophagitis, hiatal hernia, and Barrett's esophagus 2, 3, 5

Prolonged pH monitoring should be performed after suspending proton pump inhibitors for 7 days, and preferably using wireless monitoring for 96 hours if available 1, 2, 4
If the acid exposure time is less than 4.0% on all days, it is likely functional heartburn, not gastroesophageal reflux disease 4
If the acid exposure time is greater than 4.0% on one or more days, it confirms true gastroesophageal reflux disease 4

Alginate-antacids can be used for intermittent symptoms 2
Nocturnal H2 antagonists can be used for specific nocturnal symptoms 2
Baclofen can be used for regurgitation or eructation predominant symptoms 2
Prokinetics can be used only if coexisting gastroparesis is documented through a gastric emptying study 2

Invasive antireflux options should be considered if there is objective evidence of gastroesophageal reflux disease but no benefit from optimized medical therapy, after evaluating peristaltic function with high-resolution manometry and gastric emptying study if gastroparesis is suspected 2, 3