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NICE guidance - management of gastroesophageal reflux disease (GORD) in primary care in adults

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Management of Gastroesophageal reflux disease in Primary Care

Gastroesophageal reflux disease (GORD) in this guidance refers to endoscopically determined oesophagitis or endoscopy-negative reflux disease. Patients with uninvestigated 'reflux-like' symptoms should be managed as patients with uninvestigated dyspepsia. There is currently no evidence that H. pylori should be investigated in patients with GORD.

Step (A) Endoscopy

  1. if mild/moderate oesophagitis then (A.1)
  2. if severe oesophagitis then (A.2)
  3. if endoscopic negative reflux disease then (A.3)

Step (A.1) mild/moderate oesophagitis on endoscopy - Full dose PPI for one or two months

  1. if response then low-dose treatment as required - offer low-dose treatment, possibly on an as-required basis, with a limited number of repeat prescriptions then (B)
  2. if no response then double-dose PPI for one month
    1. if response then offer low-dose treatment, possibly on an as-required basis then (B)
    2. if no response then double-dose PPI for 1 month
      1. if response then (B)
      2. if no response then H2RA or for one month
        1. if response then offer low-dose treatment, possibly on an as-required basis, with a limited number of repeat prescriptions then (B)
        2. if no response then (B)

Step (A.2) severe oesophagitis on endoscopy

  1. Full-dose PPI for 8 weeks
    1. if oesophagitis persists then Full / high-dose PPI for 8 weeks
      1. otherwise if oesophagitis healed continue full-dose PPI
    2. if oesophagitis persists despite second course of full/high dose PPI for 8 weeks then refer for specialist review

Step (A.3) Endoscopic negative reflux disease - Full-dose PPI for one month

  1. if response then offer low-dose treatment, possibly on an as-required basis then (B)
  2. if no response then H2RA or for one month
    1. if no response then (B)
    2. if response then offer low-dose treatment, possibly on an as-required basis, then (B)

Step (B) Review long-term patient care at least annually to discuss medication and symptoms.

  • in some patients with an inadequate response to therapy or new emergent symptoms it may become appropriate to refer to a specialist for a second opinion.
  • review long-term patient care at least annually to discuss medication and symptoms
  • a minority of patients have persistent symptoms despite PPI therapy and this group remain a challenge to treat. Therapeutic options include adding an H2RA at bedtime
    • consider a high-dose of the initial PPI, switching to another full-dose PP or switching to another high-dose PPI

Notes:

  • PPI doses relating to management of dyspepsia, oesophagitis and peptic ulcer disease

    PPI Full/Standard dose Low dose (on demand dose) Double dose
    Esomeprazole 20 mg* once a day Not available 40 mg*** once a day
    Lansoprazole 30mg once a day 15mg per day 30 mg** twice a day
    Omeprazole 20 mg once a day 10mg* per day 40 mg once a day
    Pantoprazole 40 mg once a day 20mg per day 40mg twice a day
    Rabeprazole 20mg once a day 10mg per day 20mg twice a day
    • * lower than the licensed starting dose for esomeprazole in GORD, which is 40 mg, but considered to be dose-equivalent to other PPIs. When undertaking meta-analysis of doserelated effects, NICE classed esomeprazole 20 mg as a full-dose equivalent to omeprazole 20 mg
    • **off-label dose for GORD
    • ***40 mg is recommended as a double dose of esomeprazole because the 20-mg dose is considered equivalent to omeprazole 20 mg.

    PPI doses for severe oesophagitis

    PPI Full/Standard dose Low dose (on demand dose) Double dose/High dose
    Esomeprazole 40 mg* once a day 20mg* once a day 40 mg* twice a day
    Lansoprazole 30mg once a day 15mg per day 30 mg** twice a day
    Omeprazole 40 mg* once a day 20mg* per day 40 mg* twice a day
    Pantoprazole 40 mg once a day 20mg per day 40mg** twice a day
    Rabeprazole 20mg once a day 10mg per day 20mg** twice a day
    • *dose, specifically for severe oesophagitis
    • ** Off-label dose for GORD.

For full details then refer to the full guideline (1).

Reference:

Last reviewed 01/2021

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