Gastroesophageal Reflux Disease (GERD) Management

Medication Therapy

Baclofen is recommended as first-line pharmacologic therapy for regurgitation or belch-predominant GERD symptoms, as it inhibits transient lower esophageal sphincter relaxations, with typical dosing starting at 5-10mg three times daily, and is best for regurgitation and belch-predominant symptoms, according to the American Gastroenterological Association 1
Prokinetic agents like metoclopramide are not recommended as monotherapy for GERD due to limited efficacy and significant side effects, as stated by the American Academy of Pediatrics and the American Gastroenterological Association 2, 3

Consider objective testing (manometry, pH monitoring) to confirm diagnosis before escalating therapy, as recommended by the American Gastroenterological Association 1
Assess response after 4-8 weeks of therapy, and if inadequate response to baclofen, consider increasing dose if tolerated, switching to calcium channel blockers if spasm is the predominant feature, or adding neuromodulators for hypersensitivity, according to the American Gastroenterological Association 1

In pediatric patients, evidence for prokinetics is insufficient to support routine use in children with GERD, as stated by the American Academy of Pediatrics 2
In achalasia patients, pharmacologic therapy is generally inferior to procedural interventions, such as pneumatic dilation, POEM, or surgical myotomy, according to the American Gastroenterological Association and the European Society of Gastrointestinal Endoscopy 4, 5

The American Gastroenterological Association recommends identifying the predominant symptom pattern, with regurgitation/belching treated with baclofen as first-line, and esophageal spasm/chest pain considered for calcium channel blockers, while considering comorbidities and evaluating for contraindications 1