Initial therapy for GORD in adults

Proton pump inhibitors (PPIs) are generally preferred to H2-receptor antagonists for initial therapy of GORD because they are more effective at standard doses. Although GORD is commonly associated with impaired oesophageal motility and lower oesophageal sphincter dysfunction, prokinetic drugs are not recommended because they are relatively ineffective compared with acid suppressionSigterman, 2013.

For adults who have typical symptoms and no alarm symptoms, response to a trial of PPI therapy can help to confirm the diagnosis of GORD. It also gives the patient an indication of the degree of symptom relief they can expect from drug therapy, which allows them to identify symptom recurrence during the step-down phase of treatment.

For initial therapy of GORD in adults, use regular therapy with a PPI at the standard dose:

1esomeprazole 20 mg orally, daily, half to one hour before a meal esomeprazole esomeprazole esomeprazole

OR

1lansoprazole 30 mg orally, daily, half to one hour before a meal lansoprazole lansoprazole lansoprazole

OR

1omeprazole 20 mg orally, daily, half to one hour before a meal omeprazole omeprazole omeprazole

OR

1pantoprazole 40 mg orally, daily, half to one hour before a meal pantoprazole pantoprazole pantoprazole

OR

1rabeprazole 20 mg orally, daily, half to one hour before a meal. rabeprazole rabeprazole rabeprazole

Advise the patient to take the PPI before breakfast if symptoms occur mostly during the day, or before the evening meal if symptoms occur mostly in the evening.

The initial course of treatment should be 4 to 8 weeks. When symptom control is adequate, step down to maintenance therapy.

If symptom control is inadequate (especially after treatment at the standard dose for at least 8 weeks), check that the patient is taking the PPI regularly and at the optimal time. Consider if the patient is taking medications that could be contributing to their symptoms. If adherence to therapy is confirmed and other medications are ruled out as a contributor, refer the patient to a gastroenterologist for review. While awaiting review, consider using high-dose PPI therapy (note that a standard PPI dose given twice daily is more effective than a double dose given once daily) or combination therapy using standard-dose PPI therapy in the morning and H2-receptor antagonist therapy before bedtime (which may be helpful if the patient has overnight symptoms) (see Management of mild intermittent symptoms of gastro-oesophageal reflux in adults for dosages of H2-receptor antagonists). If symptoms still do not respond to therapy, consider other diagnoses.