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

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:

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

Reference:

• (1) NICE (September 2014).Dyspepsia and gastro-oesophageal reflux disease - Investigation and management of dyspepsia, symptoms suggestive of gastro-oesophageal reflux disease, or both