Gastroesophageal Reflux Disease Treatment

Established Pharmacologic Treatments

Proton pump inhibitors (PPIs) remain the cornerstone of GERD treatment by suppressing gastric acid production, as recommended by the American Gastroenterological Association 1, 2
H2-receptor antagonists (H2RAs) reduce acid production, though they are inferior to PPIs and limited by tachyphylaxis, but can improve nighttime reflux when added to PPI therapy, according to the American Gastroenterological Association 1, 3
Alginates form a physical barrier to reflux by creating a viscous raft that neutralizes the acid pocket in the proximal stomach, as supported by evidence from the American Gastroenterological Association 1, 2
Baclofen (a GABA-B agonist) decreases transient lower esophageal sphincter relaxations and reduces reflux episodes, though its use is limited by side effects including somnolence and dizziness, as reported in Gut 4, 5

For patients with GERD symptoms, the American College of Gastroenterology recommends starting with standard-dose PPI therapy for acid suppression 1, 6
Lifestyle modifications including weight loss, bed elevation, and avoiding food 2-3 hours before recumbency are recommended by the American College of Gastroenterology 6
For refractory symptoms, increasing PPI dose or switching to another PPI is recommended by the European Society of Gastrointestinal Motility 4, 6
Adding H2RA for nocturnal breakthrough reflux is suggested by the American College of Gastroenterology 1, 3, 6
Consider alginate as adjunctive therapy, particularly for patients with large hiatal hernias, as recommended by the European Society of Gastrointestinal Motility 4, 6
Baclofen may be added for persistent symptoms despite optimized acid suppression, though side effects limit its use, as reported in Gut 4, 5, 6

Perform upper endoscopy to rule out non-GERD etiologies such as eosinophilic esophagitis, infection, or achalasia, as recommended by the European Society of Gastrointestinal Motility 4, 5
Consider pH or impedance-pH monitoring off PPI therapy to quantify reflux and assess symptom correlation, as suggested by the American College of Gastroenterology 4, 6