First, optimize PPI dose, timing, and drug.¹⁵ Then refer PPI nonresponders for eval [C/L]:

¹⁵ Traditional delayed-release PPIs should be administered 30-60 min ac for max pH control [S/M]; newer PPIs may offer dosing flexibility relative to mealtime [C/M]. Optimize PPI: increase PPI dosing to bid or consider a switch to a different PPI [C/L]. If nocturnal sx, sleep disturbance, and/or variable schedules: consider dose-timing adjustment and/or bid dosing [S/L]. Bedtime H2RA tx can be added prn to daytime PPI tx in pts w/ nighttime sx, but tachyphylaxis may occur after several wks of use [C/L]. If PPI side-effects: switch PPIs [C/L]. PPI switching is common in practice; there are limited data to support this; no data to support switching PPIs ≥1x in partial/nonresponders. Meta-analyses fail to show significant efficacy difference for sx relief between PPIs. <br><br>¹⁶ Upper endoscopy not recommended to establish dx of GERD-related asthma, cough, laryngitis [SL]. Reflux laryngitis dx should not be based solely on laryngoscopy [S/M]. Consider endoscopy early for elderly, pts at risk for Barrett’s, noncardiac chest pain, and pts unresponsive to PPI. Consider screening for Barrett’s in high-risk pts (long GERD duration, age >50 yo, male, Caucasian) [C/M]. Routine distal esophagus bx not recommended specifically to dx GERD [S/M]. <br><br>
¹⁷ Ambulatory esophageal reflux monitoring indicated in eval of PPI-refractory pts and in situations when GERD dx is in question [S/L]; it’s the only test that can assess reflux-to-symptom association [S/L]. Reflux monitoring off meds by either pH or impedance-pH [C/M]; if on meds, should be performed w/ impedance-pH monitoring [S/M].