Optimizing PPIs for GERD

If the PPI doesn't give relief, suggest doubling the once-daily dose or going to BID before the first and last meal of the day. Baclofen 5–20 mg 3 TID
Mahitab Hany, BS Pharm, PGDipClinPharm, PGDipClinNutrition

As a GI pharmacist, you play a key role in optimizing proton pump inhibitors (PPIs) for gastroesophageal reflux disease (GERD). PPIs are still the mainstay for severe or frequent GERD symptoms, such as heartburn or regurgitation 2 or more times/week.

Recommend starting with a standard-dose PPI (omeprazole 20 mg, etc) once daily 30 to 60 min before the first meal of the day, since PPIs inhibit active proton pumps. There's no "best" PPI, all can relieve symptoms and heal erosive esophagitis. Try a different PPI if a patient reports side effects (headache, etc), but switching shouldn't impact efficacy. Refer patients who have symptoms after 14 days of an OTC PPI or alarm symptoms (dysphagia, weight loss, etc). Set the stage that PPIs are not intended for long-term use and treatment for GERD will usually be for 8 weeks.

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Image source: Am J Gastroenterol. 2022 Jan 1;117(1):27-56.
Figure 1. Diagnosis of GERD.
Abbreviations: EGD, esophagogastroduodenoscopy; GERD, gastroesophageal reflux disease; LA, Los Angeles; PPI, proton pump inhibitor; QOL, quality of life.

If the PPI doesn't give relief, suggest doubling the once-daily dose or going to BID before the first and last meal of the day. Baclofen at a dosage of 5–20 mg 3 times a day can be considered in patients with continued symptomatic reflux despite optimal PPI therapy. But even if symptoms improve, recommend stopping the PPI after 8 weeks to limit possible long-term risks (C. difficile, fractures, pneumonia, etc).

Consider a taper, since many patients report acid rebound. For example, suggest reducing the PPI from bid to once daily, then every other day to taper off over a few weeks. Advise using an antacid or H2-blocker for breakthrough symptoms. On the other hand, expect some patients, such as those with Barrett's esophagus or strictures to continue PPIs indefinitely at the lowest effective dose. Generally save high-dose PPIs (omeprazole 80 mg/day, etc) or chronic use of a PPI plus H2-blocker for refractory GERD. Reinforce lifestyle changes, such as weight loss or smoking cessation if needed and avoiding food or drink triggers. Review our note, "Management of gastroesophageal reflux disease (GERD)", for more details about treating GERD. And read "Pharmacotherapy of oral proton pump inhibitors (PPIs)", for interactions, long-term risks, etc.

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