GERD Treatments

GERD TREATMENTS

The following is a list of pharmacological treatments available for the management of gastroesophageal reflux disease (GERD), erosive esophagitis (EE), and nonerosive reflux disease (NERD). Recommendations are based on guidelines published by The American College of Gastroenterology (ACG).

Generic Brand Strength Form Dose
RECOMMENDED THERAPY
Proton Pump Inhibitors1,2,3,4
dexlansoprazole Dexilant 30mg, 60mg caps Adults and Children: <12yrs: not established. ≥12yrs: EE healing: 60mg once daily up to 8wks. Maintenance of EE healing and heartburn relief: 30mg once daily up to 4mos (12−17yrs) or up to 6mos (≥18yrs). Symptomatic NERD: 30mg once daily for 4wks. Hepatic impairment (Child-Pugh B): EE healing: 30mg daily up to 8wks; (Child-Pugh C): not recommended.
esomeprazole Nexium 20mg, 40mg caps Adults: Symptomatic GERD: 20mg once daily for 4wks; may repeat for additional 4wks. EE healing: 20mg or 40mg once daily for 4–8wks, may repeat for additional 4–8wks. Maintenance of EE healing: 20mg once daily (up to 6mos in controlled studies). Severe hepatic impairment: max 20mg once daily.
Children: <1mo (EE healing), <1yr (symptomatic GERD): not established. EE healing: 1mo–<1yr (3–5kg): 2.5mg; (>5–7.5kg): 5mg; (>7.5–12kg): 10mg; give once daily up to 6wks7. 1–11yrs (<20kg): 10mg; (≥20kg): 10mg or 20mg; give once daily up to 8wks7. 12–17yrs: 20mg or 40mg once daily for 4–8wks. Symptomatic GERD: 1–11yrs: 10mg once daily up to 8wks7. 12–17yrs: 20mg once daily for 4wks.
2.5mg, 5mg, 10mg, 20mg, 40mg granules for oral susp
Nexium I.V. 40mg pwd for IV inj or infusion after reconstitution Adults: Give by IV inj ≥3mins or infuse over 10–30mins. EE healing: 20mg or 40mg once daily for up to 10 days; switch to oral form when feasible. Severe hepatic impairment: max 20mg once daily.
Children: <1mo: not established. EE healing: infuse over 10–30mins; give once daily up to 10 days; switch to oral form when feasible. 1mo–<1yr: 0.5mg/kg. 1–17yrs (<55kg): 10mg; (≥55kg): 20mg.
lansoprazole Prevacid 15mg, 30mg caps Adults: Symptomatic GERD: 15mg once daily up to 8wks. EE healing: 30mg once daily up to 8wks; may repeat for additional 8wks. Maintenance of EE healing: 15mg once daily (up to 12mos in controlled studies). Severe hepatic impairment: 15mg once daily.
Children: <1yr: not established. 1–11yrs: Symptomatic GERD, EE healing: give once daily up to 12wks; (≤30kg): 15mg; (>30kg): 30mg. 12–17yrs: Symptomatic NERD: 15mg once daily up to 8wks. EE healing: 30mg once daily up to 8wks.
Prevacid SoluTab 15mg, 30mg ODT
omeprazole 10mg, 20mg, 40mg caps Adults: Symptomatic GERD: 20mg once daily up to 4wks. EE: 20mg once daily for 4–8wks; may repeat for additional 4wks (may give additional 4–8wks if relapse of EE or GERD symptoms occurs). Maintenance of EE healing: 20mg once daily (up to 12mos in controlled studies); max 10mg once daily in hepatic impairment, Asians.
Children: <1mo (EE), <1yr (symptomatic GERD, maintenance of EE healing): not established. EE: 1mo–<1yr (3–<5kg): 2.5mg; (5–<10kg): 5mg; (≥10kg): 10mg; give once daily up to 6wks. 1–16yrs (5–<10kg): 5mg; (10–<20kg): 10mg; (≥20kg): 20mg; give once daily for 4–8wks; may repeat for additional 4wks (may give additional 4–8wks if relapse of EE or GERD symptoms occurs). Symptomatic GERD, maintenance of EE healing: 1–16yrs (5–<10kg): 5mg; (10–<20kg): 10mg; (≥20kg): 20mg; give once daily up to 4wks (GERD) or up to 12mos in controlled studies (maintenance).
Prilosec 2.5mg, 10mg granules for oral susp
omeprazole/
sodium bicarbonate
Zegerid 20mg/1100mg, 40mg/1100mg caps Adults: Symptomatic GERD: 20mg once daily up to 4wks. EE healing: 20mg once daily for 4–8wks; may repeat for additional 4wks (may give additional 4–8wks if relapse of EE or GERD symptoms occurs). Maintenance of EE healing: 20mg once daily (up to 12mos in controlled studies); avoid use in hepatic impairment, Asians.
Children: Not established.
20mg/1680mg, 40mg/1680mg pwd for oral susp
pantoprazole Protonix 20mg, 40mg tabs Adults: EE healing: 40mg once daily up to 8wks; may repeat for additional 8wks. Maintenance of EE healing: 40mg once daily (up to 12mos in controlled studies).
Children: <5yrs: not recommended. ≥5yrs: EE healing (≥15−<40kg): 20mg; (≥40kg): 40mg; give once daily up to 8wks.
40mg granules for oral susp
Protonix I.V. 40mg pwd for IV infusion after reconstitution Adults: Infuse over 2mins or 15mins. GERD with history of EE: 40mg once daily for 7−10 days; switch to oral form when feasible.
Children: Not established.
rabeprazole Aciphex 20mg tabs Adults: Symptomatic GERD: 20mg once daily up to 4wks; may repeat for additional 4wks. EE healing: 20mg once daily for 4−8wks; may repeat additional 8wks. Maintenance of EE healing: 20mg once daily (up to 12mos in controlled studies). Severe hepatic impairment: avoid; monitor if treatment is necessary.
Children: <12yrs: not recommended. ≥12yrs: Symptomatic GERD: 20mg once daily up to 8wks.
ALTERNATIVE THERAPY
Histamine 2 Receptor Antagonists2,4,5
famotidine Pepcid 20mg, 40mg tabs Adults: Symptomatic NERD: 20mg twice daily up to 6wks. EE healing: 20mg or 40mg twice daily up to 12wks. Renal impairment (CrCl 30–60mL/min): Symptomatic NERD: 20mg once daily; EE healing: 20mg once daily or 40mg every other day6. CrCl <30mL/min: Symptomatic NERD, EE healing: 10mg once daily or 20mg every other day6.
Children: <40kg: use oral susp. GERD: Birth–<3mos: initially 0.5mg/kg/day; may increase to 1mg/kg/day. 3mos–<1yr: initially 0.5mg/kg twice daily; may increase to 1mg/kg twice daily; max 40mg/day. 1–16yrs: 0.5mg/kg twice daily; max 40mg twice daily. Treat for up to 8wks11 (birth–<1yr) or up to 6–12wks (1–16yrs).
40mg/5mL pwd for oral susp
cimetidine8 200mg, 300mg, 400mg, 800mg tabs Adults: EE healing: 800mg twice daily or 400mg 4 times daily for max 12wks. Severe renal impairment: 300mg every 12hrs; may increase to every 8hrs if needed.
Children: <16yrs: not recommended. Doses of 20–40mg/kg/day have been used.
300mg/5mL oral soln
nizatidine 150mg caps Adults: Symptomatic GERD, EE healing: 150mg twice daily for up to 12wks. Renal impairment (CrCl 20–50mL/min): 150mg once daily; (CrCl <20mL/min): 150mg every other day.
Children: <12yrs: not established. ≥12yrs: Symptomatic GERD, EE healing: 150mg twice daily for up to 8wks; max 300mg/day. Renal impairment (CrCl 20–50mL/min): 150mg once daily; (CrCl <20mL/min): 150mg every other day.
15mg/mL oral soln
Antacids9
aluminum hydroxide/ magnesium carbonate Gaviscon Extra Strength 160mg/105mg chew tabs Adults: 2–4 chew tabs or 10–20mL 4 times daily.
Children: Not recommended.
254mg/237.5mg per 5mL oral liq
aluminum hydroxide/ magnesium hydroxide/ simethicone Mylanta Maximum Strength 800mg/800mg/
80mg per 10mL
oral liq Adults and Children: <12yrs: consult physician. ≥12yrs: 10–20mL as needed between or after meals and at bedtime; max 60mL per 24hrs.
bismuth subsalicylate10 Pepto Bismol 262mg caplets, chew tabs Adults and Children: <12yrs: use children’s form. Caplets: take with water; do not chew. ≥12yrs: 2 chew tabs or caplets every 30–60mins as needed; max 16 chew tabs or caplets per 24hrs.
525mg/30mL oral susp Adults and Children: <12yrs: use children’s form. ≥12yrs: 30mL every 30mins as needed; max 240mL per 24hrs.
calcium carbonate 500mg chew tabs Adults and Children: <12yrs: not recommended. ≥12yrs: 2–4 chew tabs as symptoms occur; max 15 chew tabs per 24hrs. Pregnancy: max 10 chew tabs per 24hrs.
Pepto Kids 400mg chew tabs Adults: Use other forms.
Children: <24lbs (<2yrs): not recommended. 24–47lbs (2–5yrs): 1 chew tab as needed; max 3 chew tabs per 24hrs for 2 weeks. 48–95lbs (6–11yrs): 2 chew tabs as needed; max 6 chew tabs per 24hrs.
Tums Extra 750mg chew tabs Adults and Children: <12yrs: not recommended. ≥12yrs: 2–4 chew tabs as symptoms occur; max 10 chew tabs per 24hrs. Pregnancy: max 6 chew tabs per 24hrs.
Tums Ultra 1000mg chew tabs Adults and Children: <12yrs: not recommended. ≥12yrs: 2–3 chew tabs as symptoms occur; max 7 chew tabs per 24hrs. Pregnancy: max 5 chew tabs per 24hrs.
calcium carbonate/ magnesium hydroxide/ simethicone Mylanta Coat & Cool 1200mg/270mg/
80mg per 10mL
oral liq Adults and Children: <12yrs: consult physician. ≥12yrs: 10–20mL as needed between or after meals and at bedtime; max 60mL per 24hrs.
NOTES

Key: CrCl = creatinine clearance; EE = erosive esophagitis; H2RA = histamine 2 receptor antagonists; NERD = nonerosive reflux disease; ODT = orally-disintegrating tabs; PPI = proton pump inhibitor

 

 1 The ACG guidelines recommend that patients with classic and no alarm symptoms should be first treated with an 8-week trial of empiric PPIs once daily, 30−60mins before a meal (twice daily for 8−12wks before additional testing if patient has both extraesophageal and classic symptoms). If no response to therapy, switch only once to another PPI. For refractory GERD, defined as persistent heartburn and/or regurgitation despite 8wks of twice daily PPI (12wks for some), optimization of PPI therapy is recommended as the first step of management. Discontinue PPI if off-therapy reflux testing is negative unless other indication for PPI use exists. Refer to the estimated relative acid-suppression potencies of individual PPIs standardized to omeprazole when switching or optimizing therapy: pantoprazole (0.23), lansoprazole (0.90), omeprazole (1.00), esomeprazole (1.60), and rabeprazole (1.82).

 2 The ACG guidelines recommend an intermittent or as needed PPI therapy for heartburn symptom control in NERD. Step-down therapy to H2RAs is acceptable.

 3 PPIs should be discontinued if symptoms resolve (consider on-demand PPI if symptoms occur) and without EE or Barrett’s esophagus, however, indefinite maintenance PPI therapy is recommended for patients with LA grade C or D esophagitis.

 4 PPIs are recommended over H2RAs for healing EE and maintenance of healing for EE.

 5 The addition of as needed H2RA at bedtime may be beneficial in patients with nocturnal symptoms and those with objective evidence of nocturnal acid reflux on pH monitoring despite PPI treatment.

 6 For the 40mg twice daily regimen for EE healing, reduce to 40mg once daily for CrCl 30–60mL/min or 20mg once daily for CrCl <30mL/min.

 7 Doses over 1mg/kg/day have not been studied in patients 1–11yrs. Doses over 1.33mg/kg/day have not been studied in patients 1mo–<1yr.

 8 Use in pregnancy only if clearly needed. Avoid in nursing mothers or children under 16yrs.

 9 Antacids are recommended to be used exclusively for on-demand symptom relief. First-line therapy in pregnant patients when lifestyle modifications fail.

10 Avoid in patients with allergy to salicylates (including aspirin) or concomitant salicylate products.

11 Consider additional 4wks if benefit outweighs potential risks.

 

Not an inclusive list of medications. Please see drug monographs at www.eMPR.com and/or contact company for full drug labeling.

REFERENCES

Katz PO, Dunbar KB, Schnoll-Sussman FH, Greer KB, Yadlapati R, Spechler SJ. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol. 2022 Jan 1;117(1):27-56. doi: 10.14309/ajg.0000000000001538. PMID: 34807007; PMCID: PMC8754510.

(Created 6/2022)