Maintenance and step-down therapy for GORD in adults

Maintenance therapy for GORD aims to control symptoms, reduce the risk of developing complications of GORD and minimise risk associated with long-term use of a PPI. If initial PPI therapy provides adequate symptom control, therapy should be titrated down and continued at the lowest dose and frequency that controls symptoms, or eventually stopped—this is known as step-down therapy. Step-down therapy should be individualised. Regular attempts should be made to further reduce the dose.

Stopping PPI therapy without a gradual reduction in dosage can result in prolonged remission of symptoms in up to 30% of patients; however, in the remaining patients symptoms recur due to ongoing reflux, possibly contributed to by rebound acid hypersecretionLodrup, 2013. Symptom recurrence may be minimised by using step-down therapy, or regular therapy with an H₂-receptor antagonist or antacid.

Step-down therapy can be achieved by halving the daily dose of PPI or dosing on alternate days, then switching to therapy only on days when symptoms occur (on-demand therapy). The aim is to determine and then maintain the patient on the lowest dose of PPI consistent with adequate control of symptoms.

If symptoms recur during step-down therapy, advise patients to return to the lowest PPI dosage that provided effective symptom control. Explain to patients that their symptoms may vary over time (eg depending on diet and lifestyle factors), and therapy needs to be adjusted accordingly. It is appropriate to wait for a period of time for stabilisation and again attempt to repeat the dose reduction.

If, after several attempts at lowering the dose of the PPI, symptoms are not adequately controlled, the patient is likely to need ongoing treatment at the lowest dose that controlled symptoms.