Acid suppression continues to be the mainstay for treating GERD that does not respond to lifestyle changes and treatment. The aim of drug therapy is to reduce the amount of acid and improve any abnormalities in muscle function of the lower esophageal sphincter, esophagus, or stomach.
Most cases of gastroesophageal reflux are mild and can be managed with lifestyle changes, over-the-counter medications, and antacids.
Patients with moderate-to-severe symptoms that do not respond to lifestyle changes, or who are diagnosed at a late stage may be started on medications of varying strength, depending on their complications at diagnosis. Experts argue, however, about the best way to start drug treatment for GERD in most of these patients. The two major treatment options are known as the step-up and step-down approaches:
- Step-up. With a step-up drug approach the patient first tries an H2 blocker drug, which is available over the counter. These drugs include famotidine (Pepcid AC), cimetidine (Tagamet HB), ranitidine (Zantac 75), and nizatidine (Axid AR). If the condition fails to improve, therapy is "stepped up" to the more powerful proton-pump inhibitors (PPI), usually omeprazole (Prilosec).
- Step-down. A step-down approach first uses a more potent drug, most often a PPI, such as omeprazole (Prilosec). When patients have been symptom-free for 2 months or longer, they are then "stepped down" to a half-dose. If symptoms do not come back, the drug is stopped. If symptoms return, the patient is put on high-dose H2 blockers. Some physicians argue that the step-down approach should be used for most patients with moderate-to-severe GERD.
Review Date: 07/11/2010
Reviewed By: Reviewed by: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.