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Initial Interventions for GERD

for Health Care Providers

Table 1: Initial Interventions for GERD

Back to GERD Chapter

PPIs
  • 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 NameDosage RangeComments
Dexlansoprazole30-60 mg QDIf difficulty swallowing, can open capsule and sprinkle contents on applesauce
Esomeprazole20-40 mg QDIf difficulty swallowing, can open capsule and sprinkle contents on applesauce
Lansoprazole15-30 mg QD or 30 mg BIDIf difficulty swallowing, can open capsule and sprinkle contents on applesauce
Omeprazole20-40 mg QDIf difficulty swallowing, can open capsule and sprinkle contents on applesauce; immediate-release form contraindicated with hypocalcemia or alkalosis
Pantoprazole40 mg QD or 40 mg BIDNo dosage adjustment needed for hepatic impairment; may cause false-positive THC result on urine toxicology screen
Rabeprazole20 mg QD or 20 mg BIDDelayed-release tablet
H2RAs
  • 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.
Cimetidine800 mg BID or 800 mg TIDMultiple drug interactions (see Potential ARV Interactions)
Famotidine20 mg BID or 40 mg BIDMay decrease ATV absorption
Nizatidine150 mg BID or 300 mg BIDMay decrease ATV absorption
Ranitidine150 mg BID or 150 mg QIDMay decrease ATV absorption; may decrease FPV, LPV, RTV levels
Antacids
  • 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.)
Prokinetic Agents
Metoclopramide10-15 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)
Dietary and Lifestyle Modification
Dietary
  • 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
Lifestyle
  • 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