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

Last reviewed 01/2021

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:

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