Red Flags
- Alarm features (dysphagia, weight loss, GI bleeding, anaemia, persistent vomiting, age >50 with new symptoms) — endoscopy regardless of reflux severity[1]
- Refractory GERD on twice-daily PPI for ≥8 weeks — endoscopy + ambulatory pH/impedance; confirm reflux vs functional disorder before escalation[1]
- Barrett's oesophagus on endoscopy — surveillance per histology grade; refer for radiofrequency ablation if dysplasia[1]
- Suspected eosinophilic oesophagitis (dysphagia, food impaction, atopy) — biopsy mandatory at endoscopy; PPI plus ICS topical[1]
First-line treatment
Interventions
- Lifestyle modification[1]Weight reduction if BMI ≥25, head-of-bed elevation, avoid late meals (≥3 hours pre-bed), reduce trigger foods (spicy, fatty, citrus, chocolate, mint), smoking cessation, alcohol moderation
- Anti-reflux surgery (fundoplication)[1]PPI-refractory or PPI-intolerant patients with confirmed reflux on pH monitoring; preoperative manometry mandatory
- Magnetic sphincter augmentation (LINX)[1]Selected refractory GERD; alternative to fundoplication; preserves ability to belch and vomit
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Pantoprazole or omeprazole (PPI)[1] | Proton pump inhibitor | Pantoprazole 40 mg or omeprazole 20–40 mg PO once daily 30–60 min before breakfast for 4–8 weeks; step down to lowest effective dose for maintenance | Per weight per paediatric guidelines | First-line for symptomatic GERD; once-daily 30 min pre-breakfast better than after meals |
| Vonoprazan[1] | Potassium-competitive acid blocker (P-CAB) | 10–20 mg PO once daily | — | Newer acid-suppressant; faster onset, longer duration than PPI; effective for severe oesophagitis and refractory GERD |
| Famotidine[1] | H2 receptor antagonist | 20–40 mg PO BD | 0.5 mg/kg BD | Add at bedtime in nocturnal symptoms despite daytime PPI; mild GERD alternative |
| Antacid (calcium carbonate or aluminium-magnesium hydroxide)[1] | Antacid | PRN for breakthrough symptoms | — | Symptom relief layer on top of PPI; not maintenance therapy |
Pantoprazole or omeprazole (PPI)[1]
Proton pump inhibitor
- Adult
- Pantoprazole 40 mg or omeprazole 20–40 mg PO once daily 30–60 min before breakfast for 4–8 weeks; step down to lowest effective dose for maintenance
- Paediatric
- Per weight per paediatric guidelines
First-line for symptomatic GERD; once-daily 30 min pre-breakfast better than after meals
Vonoprazan[1]
Potassium-competitive acid blocker (P-CAB)
- Adult
- 10–20 mg PO once daily
- Paediatric
- —
Newer acid-suppressant; faster onset, longer duration than PPI; effective for severe oesophagitis and refractory GERD
Famotidine[1]
H2 receptor antagonist
- Adult
- 20–40 mg PO BD
- Paediatric
- 0.5 mg/kg BD
Add at bedtime in nocturnal symptoms despite daytime PPI; mild GERD alternative
Antacid (calcium carbonate or aluminium-magnesium hydroxide)[1]
Antacid
- Adult
- PRN for breakthrough symptoms
- Paediatric
- —
Symptom relief layer on top of PPI; not maintenance therapy
Safety-net
- Take PPI 30–60 minutes before food (typically breakfast) — taking it after meals is much less effective[1]
- Long-term PPI use is generally safe but consider periodic dose review; B12 and bone density monitoring not routinely required[1]
- New difficulty swallowing, food sticking, weight loss, or vomiting blood — same-day medical review and likely endoscopy[1]
Referral criteria
- Alarm features (dysphagia, weight loss, GI bleed, anaemia, persistent vomiting, age >50 with new symptoms)Gastroenterology for endoscopy[1]
- Refractory GERD on twice-daily PPI ≥8 weeksGastroenterology for endoscopy + pH monitoring[1]
- Barrett's oesophagusGastroenterology for surveillance and ablation as indicated[1]
- Anti-reflux surgery candidacyUpper GI surgery with manometry and pH testing[1]
Clinical summary
Diagnosis and stepped management of GERD in adults — lifestyle plus PPI for typical symptoms; endoscopic evaluation for alarm features.