GERD Management

Alarm Features — EGD First, Not a PPI Trial

Dysphagia · odynophagia · weight loss · GI bleeding or iron-deficiency anemia · persistent vomiting · age >60 with new-onset symptoms. Chest pain: rule out cardiac before attributing to reflux.

Treatment Ladder (ACG 2022)

  1. Lifestyle with evidence: weight loss, elevate head of bed, no food 2–3 h before bed, tobacco cessation. Blanket trigger-food elimination has weak evidence.
  2. Mild / intermittent: antacids, alginate (Gaviscon — post-prandial acid pocket), or PRN H2RA.
  3. H2RA scheduled: famotidine 20 mg BID (OTC) / 40 mg BID (Rx). Tachyphylaxis in 2–6 weeks of daily use — good PRN, weak maintenance.
  4. PPI standard dose × 8 weeks, 30–60 min before breakfast — the workhorse.
  5. Optimize before escalating: adherence and pre-meal timing first (~⅓ of "failures" take it wrong) → then BID PPI or switch agent.
  6. PCAB (vonoprazan) for refractory disease, LA C/D esophagitis, nocturnal breakthrough.
  7. Nocturnal breakthrough on PPI: add famotidine qHS or move to PCAB.
  8. Surgery / LINX: pH-proven GERD refractory or intolerant to meds; manometry first.

PPI Dose Converter

Standard-dose equivalence: omeprazole 20 = lansoprazole 30 = esomeprazole 20 = pantoprazole 40 = rabeprazole 20 mg. By measured potency (omeprazole equivalents): rabeprazole 20 (~36 OE) > esomeprazole 20–40 > omeprazole 20 ≈ lansoprazole 30 >> pantoprazole 40 (~9 OE). Pantoprazole failure is not a PPI-class failure — switch to rabeprazole or esomeprazole before calling it refractory.

Vonoprazan (Voquezna) — PCAB, Not a PPI

Potassium-competitive acid blocker: no acid activation needed → full effect day 1, no meal-timing requirement, stronger nocturnal suppression. No omeprazole-equivalent conversion exists — different class. Brand-only; expect prior auth. Tablets only — not a dysphagia option.

IndicationDoseDuration
Erosive esophagitis, healing20 mg daily8 wk
Erosive esophagitis, maintenance10 mg dailyup to 6 mo
Non-erosive GERD heartburn10 mg daily4 wk
H. pylori (Triple/Dual Pak)20 mg BID14 d
eGFR <30 (EE healing)10 mg daily—

Clopidogrel / CYP2C19

  • Avoid with clopidogrel: omeprazole, esomeprazole (FDA warning).
  • Preferred with clopidogrel: pantoprazole.
  • Least CYP2C19-dependent: rabeprazole — consider in rapid metabolizers failing omeprazole.

Refractory GERD Workup

  1. Confirm adherence and pre-meal timing — biggest yield.
  2. BID PPI or switch agent (esomeprazole / rabeprazole) × 8 wk.
  3. Still symptomatic → EGD (off PPI 2–4 wk if hunting erosive disease / Barrett's).
  4. EGD normal → ambulatory pH off therapy (never-proven GERD) or pH-impedance on therapy (proven GERD).
  5. Normal pH + symptoms = functional heartburn / reflux hypersensitivity → neuromodulator (low-dose TCA), not more acid suppression.
  6. Regurgitation-predominant refractory → think hiatal hernia; surgical evaluation.

Step-Down & Long-Term PPI Safety

  • Indefinite PPI: LA C/D erosive esophagitis, Barrett's, peptic stricture.
  • NERD after control: lowest effective dose → on-demand → H2RA PRN → off.
  • Taper (every-other-day × 2–4 wk), don't hard-stop — rebound acid hypersecretion mimics relapse; warn the patient.
  • Fracture / B12 / Mg / CKD / dementia / C. diff signals are weak observational associations — no surveillance labs, don't stop an indicated PPI over them (ACG 2022).

Barrett's Screening

One-time EGD if chronic GERD (≥5 yr) plus ≥3 of: male, age >50, White, central obesity, tobacco, family history of Barrett's or esophageal adenocarcinoma.

Dysphagia / Can't Swallow Pills

  • Lansoprazole ODT (Prevacid SoluTab) — dissolves on the tongue; bioequivalent to the capsule. Usual first choice.
  • Lansoprazole oral suspension packets — powder mixed with water.
  • Open-capsule sprinkle — esomeprazole or lansoprazole granules on soft food (applesauce); FDA-approved.
  • Omeprazole–sodium bicarbonate (Zegerid) — immediate-release suspension; NG-tube compatible; often available when plain omeprazole liquid is not.
  • Pantoprazole granules-for-suspension packet — mix with apple juice or applesauce.
  • Never crush rabeprazole or pantoprazole tablets (enteric coating).

Post-Bariatric Surgery

  • Prefer immediate-release, liquid, dissolvable, or opened-capsule forms; avoid enteric-coated and extended-release solids (AACE/TOS/ASMBS 2019).
  • Roux-en-Y: use soluble form or opened capsules — absorption depends on the Roux limb and common channel.
  • Prophylactic PPI is recommended 90 days to 1 year post-op depending on risk (AACE/TOS/ASMBS 2019).
  • Sleeve gastrectomy commonly worsens reflux — new/worse GERD after sleeve is expected; refractory cases may need conversion to RYGB.

Administration Pearls

  • All PPIs: empty stomach, 30–60 min before a meal. Exceptions: dexlansoprazole and vonoprazan — any time.
  • BID = before breakfast AND before dinner, not qHS.
  • Full PPI effect takes 3–5 days — tell patients not to judge at day 2. Vonoprazan works day 1.

Sources

  • Katz PO et al. ACG Clinical Guideline: GERD. Am J Gastroenterol 2022.
  • Graham DY, Tansel A. Interchangeable Use of PPIs Based on Relative Potency. Clin Gastroenterol Hepatol 2018.
  • Kirchheiner J et al. Relative Potency of PPIs — Intragastric pH. Eur J Clin Pharmacol 2009.
  • Laine L et al. PHALCON-EE: Vonoprazan vs Lansoprazole for Erosive Esophagitis. Gastroenterology 2023.
  • Voquezna (vonoprazan) FDA prescribing information.
  • Mechanick JI et al. AACE/TOS/ASMBS Perioperative Bariatric Guidelines, 2019 Update. Obesity 2020.
  • Shaheen NJ et al. ACG Clinical Guideline: Barrett's Esophagus. Am J Gastroenterol 2022.
  • Horn JR, Howden CW. Similarities and differences among delayed-release PPI formulations. Aliment Pharmacol Ther 2005.