Table 1: Initial Interventions for GERD
Back to GERD Chapter
- Available PPIs have comparable efficacy at equivalent dosages.
- Greater efficacy and more rapid symptom control than H2RAs.
- Optimal starting dosage is unclear; some authorities prefer to start with high dosages and step down to less-intensive therapy after symptom remission, others prefer to start at lower dosages and increase treatment intensity if needed.
- Should be taken a half hour before breakfast (or dinner).
- Usually well tolerated. Potential adverse effects include GI symptoms (abdominal pain, diarrhea, nausea), headache, rash, and liver toxicity.
- No dosage adjustment needed for renal impairment.
- May require lower dosage in hepatic impairment; dosage not defined.
- Decrease absorption of drugs with pH-dependent bioavailability, particularly ATV. (See Potential ARV Interactions.)
|Generic Drug Name||Dosage Range||Comments|
|Dexlansoprazole||30-60 mg QD||If difficulty swallowing, can open capsule and sprinkle contents on applesauce|
|Esomeprazole||20-40 mg QD||If difficulty swallowing, can open capsule and sprinkle contents on applesauce|
|Lansoprazole||15-30 mg QD or 30 mg BID||If difficulty swallowing, can open capsule and sprinkle contents on applesauce|
|Omeprazole||20-40 mg QD||If difficulty swallowing, can open capsule and sprinkle contents on applesauce; immediate-release form contraindicated with hypocalcemia or alkalosis|
|Pantoprazole||40 mg QD or 40 mg BID||No dosage adjustment needed for hepatic impairment; may cause false-positive THC result on urine toxicology screen|
|Rabeprazole||20 mg QD or 20 mg BID||Delayed-release tablet|
- Less effective than PPIs for acid suppression, relief of symptoms, and healing of esophagitis; approximately 40% of patients gain symptom relief. Treatment with H2RAs may be adequate for some patients.
- Potential adverse effects vary somewhat according to the specific H2RA. They include cytopenias, rash, GI intolerance, and arrhythmias.
- Dosage adjustment is required for patients with renal insufficiency.
- Cimetidine interacts significantly with many other drugs.
- See Potential ARV Interactions.
|Cimetidine||800 mg BID or 800 mg TID||Multiple drug interactions (see Potential ARV Interactions)|
|Famotidine||20 mg BID or 40 mg BID||May decrease ATV absorption|
|Nizatidine||150 mg BID or 300 mg BID||May decrease ATV absorption|
|Ranitidine||150 mg BID or 150 mg QID||May decrease ATV absorption; may decrease FPV, LPV, RTV levels|
- Typically contain aluminum hydroxide, magnesium hydroxide, calcium carbonate, sodium bicarbonate, or combinations of these compounds.
- Liquid formulation is preferable to tablets because of more rapid action.
- Usual dosage is 15-30 mL QID (after meals and at bedtime).
- If tablets are used, they should be thoroughly chewed and followed by full glass of water.
- Antacids combined with alginic acid (eg, Gaviscon) may be superior to antacids alone.
- Adverse events:
- Antacids containing magnesium: diarrhea
- Antacids containing aluminum or calcium: constipation
- Hypophosphatemia with chronic use
- Magnesium and/or aluminum retention in chronic renal failure
- Multiple drug interactions caused by binding to form insoluble complexes, including PIs and integrase inhibitors. (See Potential ARV Interactions.)
|Metoclopramide||10-15 mg QID (after meals and at bedtime)||Associated with irreversible tardive dyskinesia, other CNS effects; may consider metoclopramide as adjunctive therapy (add-on to PPI)|
- In most patients, avoiding the following is useful:
- Carbonated beverages
- Voluminous meals
- In selected patients, avoiding the following triggers may be useful:
- Fatty meals
- Sweets, including chocolate
- Spicy foods/raw onions
- Caffeinated beverages
- Citrus products/juices
- In most patients, the following are useful:
- Weight loss
- Smoking cessation
- Lying on the left side when sleeping
- Avoiding excessive physical activity (running)
- In selected patients, the following may be useful:
- Avoiding alcohol
- Elevating head of bed (for nocturnal symptoms)
From Gastroesophageal Reflux Disease
Primary Care of Veterans with HIV
Office of Clinical Public Health Programs
Veterans Health Administration, 2009