ACG Clinical Guideline for the Treatment of GERD
The American Journal of Gastroenterology
GERD MEDICAL MANAGEMENT
Management of GERD requires a multifaceted approach, taking into account the symptom presentation, endoscopic findings, and likely physiological abnormalities.
Medical management includes lifestyle modifications and pharmacologic therapy, principally with medications that reduce gastric acid secretion.
Recommendations
1. Guidelines recommend weight loss in overweight and obese patients for improvement of GERD symptoms (strong recommendation, moderate level of evidence).
2. Guidelines suggest avoiding meals within 2–3 hours of bedtime (conditional recommendation, low level of evidence).
3. Guidelines suggest avoidance of tobacco products/smoking in patients with GERD symptoms (conditional recommendation, low level of evidence).
4. Guidelines suggest avoidance of “trigger foods” for GERD symptom control (conditional recommendation, low level of evidence).
5. Guidelines suggest elevating head of bed for nighttime GERD symptoms (conditional recommendation, low level of evidence).
6. Guidelines recommend treatment with PPIs over treatment with histamine-2-receptor antagonists (H2RA) for healing EE (strong recommendation, high level of evidence).
7. Guidelines recommend treatment with PPIs over H2RA for maintenance of healing from EE (strong recommendation, moderate level of evidence).
8. Guidelines recommend PPI administration 30–60 minutes before a meal rather than at bedtime for GERD symptom control (strong recommendation, moderate level of evidence).
9. For patients with GERD who do not have EE or Barrett's esophagus, and whose symptoms have resolved with PPI therapy, an attempt should be made to discontinue PPIs or to switch to on-demand therapy in which PPIs are taken only when symptoms occur and discontinued when they are relieved (conditional recommendation, low level of evidence).
10. For patients with GERD who require maintenance therapy with PPIs, the PPIs should be administered in the lowest dose that effectively controls GERD symptoms and maintains healing of reflux esophagitis (conditional recommendation, low level of evidence).
11. Guidelines recommend against routine addition of medical therapies in PPI nonresponders (conditional recommendation, moderate level of evidence).
12. Guidelines recommend maintenance PPI therapy indefinitely or antireflux surgery for patients with LA grade C or D esophagitis (strong recommendation, moderate level of evidence).
13. Guidelines do not recommend baclofen in the absence of objective evidence of GERD (strong recommendation, moderate level of evidence).
14. Guidelines recommend against treatment with a prokinetic agent (e.g. metoclopramide) of any kind for GERD therapy unless there is objective evidence of gastroparesis (strong recommendation, low level of evidence).
15. Guidelines do not recommend sucralfate for GERD therapy except during pregnancy (strong recommendation, low level of evidence).
16. Guidelines suggest on-demand or intermittent PPI therapy for heartburn symptom control in patients with NERD (conditional recommendation, low level of evidence).
Doctors Liked to Read More
1. There is conceptual rationale for a trial of switching PPIs for patients who have not responded to one PPI. For patients who have not responded to one PPI, more than one switch to another PPI cannot be supported.
2. Use of the lowest effective PPI dose is recommended and logical but must be individualized.
3. PPIs are the most commonly prescribed medication based on ample data demonstrating consistently superior heartburn and regurgitation relief, as well as improved healing compared with H2RAs.
4. Studies on GERD treatment typically last only 8–12 weeks, in part because symptom relief and healing seem to peak in that time frame.
5. PPIs can bind only to proton pumps that are actively secreting acid. Because meals stimulate proton pump activity, enteric-coated PPIs control intragastric pH best when given before a meal (30–60 minutes before breakfast for once-daily dosing and 30–60 minutes before breakfast and dinner for twice-daily dosing). Bedtime dosing is discouraged because this is less effective than a predinner dose in acid control.
6. Dexlansoprazole, a dual delayed release PPI, in which first absorption is in the duodenum, then partially further down the small bowel, seems to have similar efficacy in pH control regardless of meal timing.
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