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Patient With GERD-Related Symptoms Alarm Symptoms
No Alarm Symptoms
PPI* test; bid for 1-2 weeks –
+ Unlikely to be GERD PPI* daily for 2 months Complete relief
Maintenance treatment (long-term)
PPI* daily
PPI* on demand/ intermittent (NERD and EE LA-A&B)
Partial/no relief
Improve PPI* dosing time and compliance
Partial/no relief
Switch to another PPI* (2 months)
Partial/no relief Partial/no relief
PPI* bid (AM & PM) for 2 months
No access to esophageal impedance
Esophageal impedance + pH
–
Positive for acid reflux
acidic reflux for weakly Positive
PPI* dosing time and compliance
Review Again
Consider adding H2RA at bedtime
Pain Modulators > Tricyclics > SSRIs
TLESR Reduction > Antireflux surgery > Pain modulators
Partial/no relief H2RA at bedtime
*Proton pump inhibitors may increase the risk of fractures of the hip, wrist, and spine with high-dose or chronic use.
Empirical therapy Predominant Symptom
and/or sour/bitter taste in mouth
Regurgitation Heartburn
Partial/ no relief
Upper endoscopy –
+ Address mucosal injury
