PHARMACOLOGICAL TREATMENT

Initial Management (8 Weeks)
• Antacids were the standard treatment in the 1970s and are still effective in controlling mild symptoms of GERD. Antacids should be taken after each meal and at bedtime.
• Histamine H2 receptor antagonists are the first line agents for patients with mild-to-moderate symptoms and grades I-II esophagitis.
• Histamine H2 receptor antagonists are effective for healing only mild esophagitis in 70-80% of patients with GERD and for providing maintenance therapy to prevent relapse.
• Tachyphylaxis has been observed, suggesting that pharmacologic tolerance can reduce the long-term efficacy of these drugs.
• Additional H2 blocker therapy has been reported to be useful in patients with severe disease (particularly those with Barrett esophagus) who have nocturnal acid breakthrough.
• Proton pump inhibitors are the most powerful medications available.
• Patients whose symptoms persist despite 6 weeks of standard doses of H2-receptor antagonist therapy should be treated with a proton pump inhibitor (once daily omeprazole or rabeprazole 20 mg, lansoprazole 30 mg, esomeprazole or pantoprazole 40 mg). The decision to prescribe proton pump inhibitors is based on the presence of persistent symptoms, not endoscopic findings
• They should be used only when GERD has been objectively documented. Proton pump inhibitors work by blocking the final step in the H+ ion secretion by the parietal cell. They have few adverse effects and are well tolerated for long-term use.
• Initial treatment of GERD should consist of an eight-week trial of PPI therapy, more long-term behavioral modifications, and possibly endoscopy, designed to help reduce reflux both structurally and promoting proper function of the lower esophageal sphincter (LES), and also reducing acidity of gastric juices.
• Following up at 8 weeks to see if there has been some improvement in symptoms may be done. If there is no improvement, the patient should be referred for endoscopy
• If these modifications have already been tried by the patient and have been successful, then maintenance therapy would be appropriate.
• In patients who incompletely respond to a trial of either nonprescription or prescription H2RA, PPIs are preferred over continuing H2RA therapy because of their greater efficacy and faster symptom control, and the limited benefit gained from extending therapy with the same or higher dose of H2RA [7].
• Second-line therapy with H2RAs also takes longer to achieve a response rate similar to that with PPIs. Patients who had inadequate responses to at least 12 weeks of standard-dose H2RA may need to take an H2RA for 8 to 12 weeks more (even at double doses) to achieve a cumulative healing or heartburn resolution rate close to that seen with just 4 weeks of PPI therapy
• Switch to a PPI if there is an incomplete response to H2RA therapy
• The initial treatment approach may be either step-down therapy (PPI first) or step-up therapy (H2RA first)

• Prokinetic drugs (bethanechol, metoclopramide, cisapride, and tegaserod) have the potential to be useful adjuncts in the treatment of GERD by counteracting some physiologic abnormalities that are present[13]
• These agents are somewhat effective but only in patients with mild symptoms; other patients usually require additional acid-suppressing medications such as proton pump inhibitors [13].
• Long-term use of prokinetic agents may have serious, even potentially fatal, complications and should be discouraged [13].

Inadequate Response to PPI Therapy
• If there is an inadequate response to a course of standard-dose PPI, extend treatment with either the same or double dose of PPI
• The patient who does not respond to a course of standard-dose PPI should be referred for further diagnostic testing
• If Esomeprazole has not been used at this point, it would be reasonable to try a therapeutic trial