Prescribe PPIs in the lowest effective dose for GERD


Dr J S Rajkumar, Chairman and Chief Surgeon, Rigid Hospitals, Chennai; Senior Consultant, Laparoscopic Surgeon, VPS, Burjeel group, Dubai    25 November 2021

There is no single test to diagnose GERD. Instead, diagnosis is based on symptoms, response to therapy, endoscopy and reflux monitoring considered as a whole, states the latest updated clinical guideline for the diagnosis and management of gastroesophageal reflux disease (GERD), which were last published in 2013.

GERD has been defined in the guideline as “the condition in which the reflux of gastric contents into the esophagus results in symptoms and/or complications” or “the presence of characteristic mucosal injury seen at endoscopy and/or abnormal esophageal acid exposure demonstrated on a reflux monitoring study”.

While heartburn and regurgitation are the classical symptoms of acid reflux, some patients may have extra-esophageal symptoms such as hoarseness, throat clearing, chronic cough. In some patients, chest pain may be the only manifestation of reflux disease. Such patients should be carefully investigated for non-GERD etiology before diagnosing them as having GERD.

A trial of empiric PPIs once daily before a meal for 8 weeks is recommended for patients who exhibit the typical symptoms of heartburn and regurgitation and no alarm symptoms. The PPIs may be stopped after 8 weeks, if symptoms resolve. But in case of insufficient response to PPIs or recurrence of symptoms after discontinuation of PPIs, diagnostic endoscopy, ideally after PPIs are stopped for 2 to 4 weeks. However, patients with alarm symptoms such as GI bleeding or weight loss or those who have several risk factors for Barrett’s esophagus should undergo endoscopy at the initial evaluation.

Endoscopy and/or reflux monitoring is recommended in patients who have chest pain as the only symptom of GERD and in whom heart disease has been ruled out. The guideline recommends against the use of barium swallow or high-resolution manometry or reflux monitoring off therapy solely as a diagnostic test for GERD.

The role of dietary and lifestyle modification for symptomatic improvement has been reiterated. The guideline strongly recommends PPIs in preference to histamine-2-receptor antagonists (H2RA) for healing of erosive esophagitis as well as for maintenance of healing citing faster healing rate as well as greater relief of symptoms such as heartburn. For patients with LA grade C or D esophagitis, PPIs as maintenance therapy or antireflux surgery is recommended. PPIs should be prescribed in the lowest effective dose (individualized) when used as maintenance therapy. The authors write, “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.”

Patients who present with both the typical reflux symptoms as well as extraesophageal symptoms should be given a trial of twice-daily PPI therapy for 8 to 12 weeks before further investigations.

Other key recommendations include use of prokinetic agents only in the presence of objective evidence of gastroparesis, use of sucralfate only during pregnancy and on-demand or intermittent PPI therapy for heartburn symptom control in patients with nonerosive reflux disease (NERD).

Some patients continue to have GERD symptoms despite PPIs or “refractory GERD”. The guideline suggests that persistence of symptoms may be due to other conditions such as eosinophlic esophagitis, achalasia, gastroparesis or heart disease or the symptoms may be functional in nature.

Surgical or endoscopic antireflux procedures are only recommended in patients with objective evidence of GERD, especially those who have severe reflux esophagitis (LA grade C or D), large hiatal hernias, and/or persistent, troublesome GERD symptoms.

The guideline has also addressed the long-term safety concerns with PPIs such as intestinal infections, pneumonia, gastric cancer, osteoporosis-related bone fractures, chronic kidney disease, nutritional deficiencies, heart attacks, strokes, dementia, and early death. But evidence shows only an association and does not establish a cause-and-effect relationship between long term use of PPIs and adverse effects. It further states “Nevertheless, we cannot exclude the possibility that PPIs might confer a small increase in the risk of developing these adverse conditions. For the treatment of GERD, gastroenterologists generally agree that the well-established benefits of PPIs far outweigh their theoretical risks.”

The complete guideline is published online November 22, 2021 in the American Journal of Gastroenterology.


  1. Katz PO, et al. ACG clinical guideline for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2021 Nov 22. doi: 10.14309/ajg.0000000000001538.

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