GERD Treatment Guidelines Summary
Current recommendations from the American College of Gastroenterology regarding treatment guidelines for gastroesophageal reflux disease include the following:
Patients who present with symptoms of gastroesophageal reflux disease with mild symptoms should be treated with:
1. Lifestyle changes as previously described
2. Initial trial of patient-directed therapy with over-the-counter H2 antagonists or antacids
Lifestyle modifications include:
1. Accomplish weight loss if obese
2. Avoid lying down after meals
3. Avoid late night meals
4. Elevate the head of your bed by 6 inches. Preferably using wooden blocks placed under the head of the bed.
5. Avoid wearing tight-fitting clothes
6. Avoidance of dietary irritants such as:
A. Fat
B. Chocolate
C. Caffeine
D. Spearmint/peppermint
7. Avoid agents which lower the lower esophageal sphincter pressure:
A. Calcium channel blockers
B. Theophylline
C. Anticholinergic medications
8. Discontinuance of tobacco use
9. Stop or reduce alcohol use
10. Avoid non-steroidal antiinflammatory drugs
Should initial treatment with over-the-counter antagonists/antacids and lifestyle modifications be effective, this treatment regimen is recommended to be continued for an indefinite period.
If the patient develops more symptoms or has an inadequate response then the following recommendations are made.
1. Continue lifestyle changes as previously noted
2. Initiation of prescription strength histamine 2 antagonist therapy, proton pump inhibitor therapy or pro-motility agents
The medications used in this group are usually prescribed in the following doses:
1. Histamine 2 receptor antagonist therapy:
A. Cimetidine 400 mg po bid
B. Ranitidine 150 mg po bid
C. Nizatidine 150 mg po bid
D. Famotidine 20 mg po bid
2. Proton pump inhibitors are usually prescribed in the following doses.
A. Omeprazole (Prilosec) 20 mg po qd
B. Lansoprazole (Prevacid) 30 mg po qd
C. Rabeprazole (Aciphex) 20 mg po qd
D. Pantoprazole (Protonix) 40 mg po qd
Pro-kinetic agents are of limited availability. The single agent in this class that will be available during the rest of the year 2000 is metoclopramide. Metoclopramide is prescribed as 10 mg ½ hour before meals and at hours of bed.
Assessment of response is then reevaluated at 8-12 weeks worth of treatment. If the patient does have an adequate response during this period of time, patients may then be discontinued from this treatment regimen. Should the patient relapse, reinstitution with this treatment regimen for 8-12 weeks, endoscopic evaluation and consideration to maintenance therapy with either histamine 2 receptor antagonists or proton pump inhibitors is recommended. Titration of medication dose to the lowest possible dose is recommended.
If patients do not have an adequate response to this, endoscopy should be performed. Proton pump inhibitors should be prescribed if they have not already been instituted. Consideration to increasing the dose of proton pump inhibitors to a bid basis may be necessary. Some patients respond to increasing the dose of histamine 2 receptor antagonists. This may also be affective.
Jonathan E. Jensen, MD FACP
Colorado Center for Digestive Disorders
July 9, 2000
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