By rray, 23 December, 2014 Increase PPI dosing<sup>19</sup> to bid or consider a switch to a different PPI<sup>20</sup> [C/L]
By rray, 23 December, 2014 If nocturnal sx, sleep disturbance, &/or variable schedules: consider dose-timing<sup>19</sup> adjustment &/or bid dosing [S/L]. Bedtime H2RA can be added prn to daytime PPI tx for nighttime sx, but tachyphylaxis may occur after several wks of use [C/L].
By rray, 23 December, 2014 First, optimize PPI dose, timing, and drug.<sup>15</sup> Then refer PPI nonresponders for eval [C/L]:
By rray, 23 December, 2014 Not recommended: esophageal manometry [S/L], <i>H. pylori</i> screen [S/L], barium radiographs [S/H]
By rray, 23 December, 2014 If alarm sx (eg, dysphagia) or high risk of GERD complications: endoscopy<sup>16</sup> recommended
By rray, 23 December, 2014 If extra-esophageal sx persist despite PPI optimization: concomitant evaluation by ENT, pulmonary, and allergy specialists [S/L]; if refractory after these evals negative: ambulatory reflux<sup>17</sup> monitoring [S/L]
By rray, 23 December, 2014 If typical/dyspeptic sx PPI-refractory: upper endoscopy<sup>16</sup> to r/o non-GERD etiologies [C/L]; if endoscopy negative: ambulatory reflux<sup>17</sup> monitoring [S/L]; if tests negative: unlikely to have GERD, so discontinue PPI [S/L]