GERD Pharmacotherapy Review: Nonpregnant Adults
From the 2022 American College of Gastroenterology (ACG) Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease
Diagnosis Chronic Management
In general, PPIs are recommended over H2RAs for the treatment of GERD due to evidence demonstrating
Symptoms of GERD superior symptom relief and faster esophageal healing.
(e.g., heartburn, regurgitation) PPIs are recommended to be taken 30 to 60 minutes prior to a meal (instead of at bedtime). With once-daily dosing, the
optimal timing is 30 to 60 minutes prior to the first meal of the day. Available data suggest no clinically significant difference
between PPIs in terms of esophageal healing and symptom relief.
Alarm symptoms* or multiple risk factors^ for Barrett’s esophagus? Diagnosis of GERD
An appropriate trial
Initiate or continue PPI therapy of PPI therapy is
Yes No 8 weeks
EGD 8-week trial of once-daily PPI ‡
Adequate response?*
Objective evidence? † Adequate response?** Consider antacids
as adjunct therapy
for as-needed
Yes symptom relief No
EE LA grade C or D or Barrett’s esophagus? Partial response?
Yes No Yes No
Diagnosis Specialist Diagnosis Stop PPI for
of
ofGERD^^
GERD referral for of
ofGERD^^
GERD 2-4 weeks
additional
Yes No Yes No
testing EGD
* e.g., dysphagia, unintentional weight loss, evidence of GI bleed Continue PPI Consider discontinuation
Diagnosis Consider increasing
Diagnosis Switch to different PPI
indefinitely (or of
as-needed
^ e.g., family history, age >50 years, male sex, obesity, smoking GERD use) the PPI
of dosage
GERD and/or (one time only)
† • The following EGD findings are considered diagnostic of GERD: of PPI therapy if dosing frequency †
• LA grade B erosive esophagitis plus classic GERD symptoms and response to PPI therapy symptoms have resolved^
• LA grade C or D erosive esophagitis
• Barrett’s esophagus segment >3 cm (with intestinal metaplasia on biopsy)
• With LA grade C or D erosive esophagitis, perform additional endoscopy after adequate course of PPI therapy Alternatively, H2RA The routine use of add-on therapy
- - to assess for Barrett's esophagus (evidence of Barrett's may be obscured in more severe cases of erosive esophagitis). may be considered (e.g., PPI plus H2RA) is not recommended in
‡ With once-daily dosing, the optimal timing is 30 to 60 minutes prior to the first meal of the day. in place of PPI those that do not respond to PPI monotherapy.
** e.g., resolution or significant improvement in symptoms
If response is inadequate,
^^ GERD can be further categorized as erosive (e.g., erosive esophagitis) or nonerosive (e.g., nonerosive reflux disease) - - referral to a specialist is warranted.
-based on the results of objective assessments. Those with evidence of Barrett’s esophagus should be referred to a specialist.
For those that require PPI therapy,
use the lowest effective dose
Vonoprazan is a first-in-class potassium-competitive acid blocker (PCAB).
The use of vonoprazan is not addressed in the current ACG guidelines.
* e.g., resolution or significant improvement in symptoms
Non-Pharmacological Treatment ^ Symptom relapse is likely
However, it is reasonable to consider its use in patients with GERD who are
indicated for PPI therapy, if PPIs are not tolerated or are not effective.
† Do not exceed FDA-approved dosing
The following diet and lifestyle interventions are reasonable for all patients with GERD:
• Avoid fatty, spicy, and acidic foods/drinks
• Maintain a healthy weight (BMI 18.5-24.9) EE: erosive esophagitis EGD: esophagogastroduodenoscopy
• Avoid tobacco products GERD: gastroesophageal reflux disease H2RA: histamine-2 receptor antagonist
• Avoid foods 2-3 hours before bed
LA: Los Angeles classification system PPI: proton pump inhibitor
• Elevate head of bed via foam/pillow wedge
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Last Updated: 9/2024 ® 2024 Cosmas Health, Inc. and/or its affiliates. All rights reserved.
