How should I manage a patient with persistent GERD symptoms despite a trial of a full-dose PPI?

For patients with persistent or recurrent GORD symptoms despite a full-dose PPI, consider prescribing a further course of a full-dose PPI for 1 month, depending on clinical judgement ¹.

If symptoms persist, consider increasing to a double dose of the initial PPI for 1 month, or adding in a histamine (H2)-receptor antagonist (H2RA) at bedtime, especially if there are nocturnal symptoms ¹.

In cases of endoscopy-negative reflux disease with ongoing symptoms, switching to an H2RA for one month may be appropriate ¹.

If symptoms are severe or ongoing after initial management, consider a high dose of the PPI or switching to an alternative full-dose or high-dose PPI for up to 8 weeks ¹.

For patients with controlled severe oesophagitis, long-term full-dose PPI as maintenance therapy may be offered, and ongoing symptoms should prompt consideration of switching PPI or specialist referral ¹.

Regular review and assessment for alarm symptoms or complications are recommended, and if symptoms are refractory, referral to a gastroenterologist for further investigation and management should be considered ¹.