📋 Key Information Summary
- Gastro-oesophageal reflux disease (GERD) is defined as troublesome symptoms or complications resulting from reflux of gastric contents into the oesophagus, affecting approximately 10–15% of Australian adults.
- Typical symptoms include heartburn and regurgitation; a clinical diagnosis can be made confidently when these are the presenting complaint and no alarm features are present.
- Alarm features — dysphagia, odynophagia, unintentional weight loss, gastrointestinal bleeding, iron-deficiency anaemia, and recurrent vomiting — mandate prompt endoscopy or specialist referral.
- Initial non-pharmacologic management includes weight loss (if BMI ≥ 25), elevation of the head of bed, avoidance of late-night meals, reduction of trigger foods (fatty, spicy, acidic, caffeine, chocolate, mint), and cessation of smoking and excess alcohol.
- First-line acid-suppressive therapy is a proton-pump inhibitor (PPI) once daily taken 30–60 minutes before breakfast for 4–8 weeks; options include omeprazole, esomeprazole, lansoprazole, pantoprazole, or rabeprazole.
- If symptoms persist after an adequate PPI trial, confirm adherence, consider twice-daily dosing (split before breakfast and dinner), or referral for diagnostic testing including oesophageal pH monitoring and manometry.
- Histamine H₂-receptor antagonists (e.g., famotidine) may be used as step-up therapy for mild symptoms or as nocturnal acid breakthrough adjunct, but are less effective than PPIs for moderate–severe GERD.
- Long-term PPI use should be reviewed annually; attempt step-down to the lowest effective dose or on-demand therapy. Long-term PPIs carry small risks of hypomagnesaemia, Clostridioides difficile infection, vitamin B₁₂ deficiency, and fractures in the elderly.
- Endoscopy is recommended for Barrett's oesophagus screening in patients with chronic GERD symptoms (≥ 5 years) plus additional risk factors: male sex, age > 50, central obesity, white race, smoking, or family history of Barrett's/oesophageal adenocarcinoma.
- Anti-reflux surgery (laparoscopic fundoplication) or newer endoscopic therapies may be considered for patients with objectively proven GERD who desire definitive treatment, have medication intolerance, or experience persistent symptoms despite optimised PPI therapy.
- Aboriginal and Torres Strait Islander peoples experience higher rates of Helicobacter pylori infection, delayed diagnosis, and barriers to specialist access; culturally safe care and proactive screening are essential.
Introduction & Australian Epidemiology
Gastro-oesophageal reflux disease (GERD) is a chronic, relapsing condition characterised by reflux of gastric contents into the oesophagus causing troublesome symptoms and/or complications. It is one of the most common gastrointestinal conditions managed in Australian general practice, with an estimated prevalence of 10–15% of adults experiencing at least weekly symptoms and up to 30% reporting monthly episodes.
GERD imposes a substantial healthcare burden in Australia. Direct costs include prescription and over-the-counter proton-pump inhibitor (PPI) use (one of the most frequently dispensed PBS medication classes), endoscopic procedures, and specialist referrals. Indirect costs relate to reduced quality of life, lost productivity, and complications such as erosive oesophagitis, Barrett's oesophagus, and rarely oesophageal adenocarcinoma.
The condition affects all age groups but prevalence increases with age, peaking in the 45–65-year age group. Obesity is a strong and modifiable risk factor, and with rising obesity rates in Australia, GERD-related presentations are anticipated to increase. GERD is slightly more common in males, and male sex is an independent risk factor for erosive disease and Barrett's oesophagus.
Australian burden: PPIs were dispensed to over 11 million PBS prescriptions in 2022–23, making them among the most commonly subsidised medications nationally. Up to 40% of Australians report using PPIs beyond the recommended treatment duration without documented reassessment.
Key Risk Factors in the Australian Context
| Risk Factor | Details | Australian Relevance |
|---|---|---|
| Obesity (BMI ≥ 30) | OR 2.0–3.0 for GERD symptoms vs normal weight | ~31% of Australian adults are obese (ABS 2022) |
| Smoking | Reduces lower oesophageal sphincter (LOS) tone | ~10% daily smoking prevalence nationally |
| Hiatal hernia | Disrupts anti-reflux barrier; found in ~60% of erosive GERD | Increases with age; common incidental finding |
| Pregnancy | Mechanical and hormonal; affects up to 80% in 3rd trimester | ~300,000 pregnancies/year nationally |
| Medications | CCBs, nitrates, anticholinergics, NSAIDs, bisphosphonates | Widely prescribed in elderly populations |
| Connective tissue disease | Scleroderma — severe dysmotility and reflux | Specialist rheumatology co-management needed |
Typical Symptoms & Initial Diagnosis
GERD diagnosis is primarily clinical, based on a characteristic symptom history. The two cardinal symptoms are heartburn (a retrosternal burning sensation rising from the epigastrium towards the throat) and regurgitation (the effortless return of gastric contents into the pharynx or mouth). When these are the predominant presenting features and no alarm features are present, the clinician can make a presumptive diagnosis of GERD with high specificity (approximately 80–90%).
Typical Symptoms
- Heartburn: Retrosternal burning, often postprandial, worse when supine or bending over; relieved by antacids or acid suppression.
- Regurgitation: Effortless return of sour or bitter gastric contents, often worse at night or after large meals.
- Epigastric pain or discomfort: May overlap with functional dyspepsia (Rome IV criteria should be applied if symptoms are not typical).
- Water brash: Sudden hypersalivation during reflux episodes (less common).
Atypical / Extra-Oesophageal Symptoms
GERD may present with or contribute to extra-oesophageal symptoms. Causation is harder to establish and empiric PPI trials are longer (8–12 weeks, often twice-daily dosing). These include:
- Chronic cough (particularly nocturnal)
- Laryngitis, hoarseness, globus sensation
- Non-cardiac chest pain
- Worsening asthma symptoms
- Dental erosions (dental referral may be first presentation)
Alarm features requiring urgent investigation: Dysphagia (inability to pass solids/liquids), odynophagia (painful swallowing), unexplained weight loss (> 5% body weight in 6 months), gastrointestinal bleeding (haematemesis, melaena, iron-deficiency anaemia), recurrent vomiting, and progressive symptoms despite adequate therapy. These warrant urgent endoscopy — do NOT empirically trial PPIs without investigation.
Diagnostic Approach
1
Clinical Assessment
Characterise symptom pattern, frequency, severity, dietary triggers, medications, and alarm features. Use validated tools if available (e.g., GERD-Q questionnaire).
2
Exclude Alarm Features
If absent, proceed with empiric management. If present, arrange urgent upper GI endoscopy (MBS item 30473).
3
Empiric PPI Trial
Standard-dose PPI once daily for 4–8 weeks. Symptom response supports GERD diagnosis (PPI test sensitivity ~78%).
4
Non-responders
Confirm adherence, review timing (pre-meal), consider twice-daily dosing or H₂RA addition. If still unresponsive, refer for oesophageal physiology testing.
Differentiating GERD from Mimics
| Condition | Key Distinguishing Features | Diagnostic Approach |
|---|---|---|
| Functional dyspepsia (Rome IV) | Epigastric burning/pain, early satiety, postprandial fullness without heartburn/regurgitation | Clinical criteria; H. pylori test-and-treat; endoscopy if alarm features |
| Eosinophilic oesophagitis | Young male, dysphagia, food bolus obstruction, atopic history, PPI non-response | Endoscopy with biopsies (≥ 15 eos/HPF) |
| Cardiac chest pain | Exertional, associated dyspnoea/diaphoresis, risk factors for IHD | ECG, troponin, cardiology referral |
| Peptic ulcer disease | Epigastric pain, nocturnal, relieved by food or antacids; NSAID use | Endoscopy; H. pylori testing |
| Gastroparesis | Nausea, vomiting, early satiety, bloating; diabetic or post-surgical | Gastric emptying scintigraphy |
Lifestyle & Non-Pharmacologic Therapy
Lifestyle modification is the cornerstone of GERD management and should be recommended to all patients, whether as sole therapy for mild disease or as adjunctive measures alongside pharmacologic treatment. The evidence base for individual interventions varies, but the cumulative effect of multiple modifications is clinically meaningful.
🎯 Strongest Evidence
- Weight loss: Highest-quality evidence; a 10% reduction in body weight significantly decreases reflux episodes. OR for GERD symptoms drops from ~2.5 to ~1.3 with weight normalisation. Essential advice for overweight/obese patients (BMI ≥ 25).
- Head-of-bed elevation: Raise the head of bed by 15–20 cm using bed blocks or a wedge pillow (extra pillows alone are insufficient). Reduces nocturnal reflux, acid clearance time, and symptom severity.
- Avoidance of late meals: No food intake within 2–3 hours of lying down. Late-night eating increases nocturnal oesophageal acid exposure.
📝 Additional Measures
- Smoking cessation: Reduces LOS relaxation frequency, improves oesophageal clearance, and has general health benefits. Refer to Quitline (13 7848) or GP management plan.
- Alcohol reduction: Alcohol directly irritates oesophageal mucosa, increases acid secretion, and reduces LOS tone. Limit to ≤ 10 standard drinks/week per NHMRC guidelines.
- Dietary modification: Individual trigger avoidance; common triggers include fatty/fried foods, spicy foods, citrus, tomato, chocolate, mint, caffeine, carbonated beverages. Evidence for universal restriction is limited — patient-specific triggers should be identified through a food diary.
- Left lateral decubitus sleeping: Anatomically reduces reflux compared to right lateral or supine position.
Patient counselling note: Lifestyle modifications alone are generally insufficient for moderate–severe GERD or erosive oesophagitis but remain essential adjuncts. Emphasise that weight loss and smoking cessation provide the greatest symptomatic benefit and reduce long-term complications.
Medication Review in GERD
Medications that may exacerbate GERD and should be reviewed or substituted where clinically appropriate:
| Drug Class | Mechanism of Worsening | Alternative / Action |
|---|---|---|
| Calcium-channel blockers (e.g., amlodipine) | Reduce LOS tone | Consider ARB/ACEi if clinically appropriate |
| Nitrates (GTN, isosorbide) | Reduce LOS tone | Often unavoidable; counsel and increase PPI |
| NSAIDs / aspirin | Mucosal irritation, direct oesophageal injury | Use with food and water; consider paracetamol or topical NSAIDs; co-prescribe PPI if ongoing NSAID use |
| Anticholinergics (e.g., oxybutynin) | Reduce LOS tone, impair motility | Review indication; use lowest effective dose |
| Bisphosphonates (alendronate) | Direct oesophageal mucosal injury | Ensure strict upright posture and water intake; consider denosumab as alternative |
| Theophylline | Reduces LOS tone | Consider alternative bronchodilators |
Acid-Suppressive Therapy
Pharmacologic acid suppression is the mainstay of GERD treatment. Proton-pump inhibitors (PPIs) are the most effective class, achieving symptom relief in 70–80% of patients with erosive oesophagitis and 50–60% with non-erosive reflux disease (NERD). Treatment strategy should follow a step-up (for mild disease) or step-down (for severe disease) approach.
Pharmacologic Step-Up Approach
1
Antacids & Alginates (Mild/Intermittent)
Antacids (e.g., Mylanta®, Gaviscon®) provide rapid but short-lived symptom relief. Alginate-antacid combinations (Gaviscon Advance®) form a raft over the gastric contents, reducing postprandial reflux episodes. Suitable for infrequent symptoms. Not PBS-listed (OTC, ~–15).
2
H₂-Receptor Antagonists (Mild–Moderate)
Famotidine 20 mg BD or 40 mg nocte; ranitidine no longer available in Australia. H₂RAs are less effective than PPIs but useful for nocturnal acid breakthrough or step-up from antacids. Tachyphylaxis develops within 2–6 weeks of regular use.
3
Proton-Pump Inhibitors (Moderate–Severe / First-Line)
Standard-dose PPI once daily 30–60 min before breakfast for 4–8 weeks is the recommended first-line for typical symptoms. Trial 8–12 weeks for atypical/extra-oesophageal symptoms.
Proton-Pump Inhibitors — Australian PBS Options
Omeprazole
Losec® · Generic · PPI
Adult dose
20 mg PO once daily (30–60 min before breakfast); 40 mg for erosive oesophagitis
Paediatric dose
≥ 1 year: 0.7–3.5 mg/kg/day PO (max 40 mg); specialist initiation recommended < 12 years
Duration
4–8 weeks (initial); reassess before continuing long-term
Renal adjustment
No adjustment required
Hepatic adjustment
Consider dose reduction in severe hepatic impairment (Child-Pugh C)
PBS status
✔ PBS General Benefit
Esomeprazole
Nexium® · Generic · PPI
Adult dose
20 mg PO once daily; 40 mg for erosive oesophagitis or H. pylori eradication
Paediatric dose
≥ 1 year: weight-based dosing; specialist initiation < 12 years
Duration
4–8 weeks initial; up to 6 months for erosive oesophagitis healing
Renal adjustment
No adjustment required
Hepatic adjustment
Max 20 mg in severe hepatic impairment
PBS status
✔ PBS General Benefit
Pantoprazole
Somac® · Generic · PPI
Adult dose
40 mg PO once daily; 20 mg for maintenance
Paediatric dose
≥ 6 years: 20 mg once daily (limited data); specialist supervision
Duration
4–8 weeks initial
Renal adjustment
No adjustment required
Hepatic adjustment
Max 20 mg/day in severe impairment
PBS status
✔ PBS General Benefit
Lansoprazole
Zoton® · Generic · PPI
Adult dose
15–30 mg PO once daily (before breakfast)
Paediatric dose
≥ 1 year: 0.5–2 mg/kg/day (max 30 mg); specialist supervision
Duration
4–8 weeks initial
Renal adjustment
No adjustment required
Hepatic adjustment
Use with caution in severe impairment
PBS status
✔ PBS General Benefit
Rabeprazole
Pariet® · Generic · PPI
Adult dose
20 mg PO once daily; 10 mg for maintenance
Paediatric dose
Not recommended < 12 years
Duration
4–8 weeks initial
Renal adjustment
No adjustment required
Hepatic adjustment
Use with caution in moderate–severe impairment
PBS status
✔ PBS General Benefit
Famotidine
Generic · H₂-Receptor Antagonist
Adult dose
20 mg PO BD or 40 mg once daily at night
Paediatric dose
0.5 mg/kg/day PO (max 40 mg); divide BD
Duration
As needed; tachyphylaxis with regular use beyond 2–6 weeks
Renal adjustment
CrCl < 30 mL/min: reduce dose by 50% or extend interval
Hepatic adjustment
No specific adjustment; use with caution
PBS status
✔ PBS General Benefit
PPI Prescribing Pearls
- Timing is critical: Take 30–60 minutes before a meal (ideally breakfast) for maximal acid suppression. Food activates parietal cells, and PPIs bind only to active proton pumps.
- If once-daily PPI insufficient: Split dose — half before breakfast, half before dinner (superior to double-dose at once for 24-hour pH control).
- PPI–drug interactions: Reduced absorption of clopidogrel (omeprazole > pantoprazole — use pantoprazole if combination required); increased methotrexate levels; reduced absorption of azole antifungals, iron, and B₁₂.
- Refractory symptoms: Ensure adherence, correct timing, and exclude functional heartburn (PPI non-response in up to 30–40%). Consider ambulatory pH monitoring off therapy (MBS item 12203).
Deprescribing PPIs: After 4–8 weeks of symptom control, step down to the lowest effective dose or attempt on-demand therapy. Abrupt cessation may cause rebound acid hypersecretion — taper over 2–4 weeks (e.g., reduce dose by 50% or switch to alternate-day dosing, then to H₂RA as needed).
Alarm Features & Atypical Symptoms
Certain clinical features should prompt urgent investigation rather than empirical treatment. These alarm features may indicate complications of GERD (strictures, Barrett's oesophagus, adenocarcinoma) or an alternative serious diagnosis.
Alarm Features Requiring Endoscopy
Urgent
GI Bleeding / Anaemia
Haematemesis, melaena, iron-deficiency anaemia (Hb < 120 g/L F, < 130 g/L M). Exclude peptic ulcer, malignancy, Cameron lesions in hiatal hernia.
Setting: Urgent endoscopy within 2 weeks (category 2)
Emergent
Dysphagia / Odynophagia
Progressive dysphagia (solids then liquids) suggests stricture or malignancy. Acute food bolus obstruction is an emergency. Odynophagia may indicate severe oesophagitis, candidiasis, or pill-induced injury.
Setting: Endoscopy within 2 weeks (category 2); emergency if complete obstruction
Urgent
Weight Loss / Recurrent Vomiting
Unintentional weight loss > 5% over 6 months or persistent vomiting raises concern for malignancy, gastric outlet obstruction, or gastroparesis.
Setting: Urgent endoscopy; consider CT abdomen if malignancy suspected
Do NOT prescribe empiric PPIs for patients with alarm features. Up to 10% of oesophageal and gastric cancers present initially as "reflux." An empiric PPI trial may mask symptoms and delay diagnosis by weeks to months. Refer directly for endoscopy (MBS item 30473) or contact your local gastroenterology service.
Atypical / Extra-Oesophageal Manifestations
Establishing GERD as the cause of extra-oesophageal symptoms is challenging because the relationship is often associative rather than causative. Key considerations:
| Manifestation | Approach | Notes |
|---|---|---|
| Chronic cough | Exclude asthma, post-nasal drip, ACEi use, smoking. Empiric twice-daily PPI for 8–12 weeks. If no response, 24-hr pH monitoring. | GERD accounts for ~25% of chronic cough referrals |
| Laryngopharyngeal reflux (LPR) | Hoarseness, globus, throat clearing. Twice-daily PPI for 8–12 weeks. ENT referral for laryngoscopy. | PPI response rate lower (~30%) than typical GERD; other causes common |
| Non-cardiac chest pain | Must exclude cardiac causes first (ECG, troponin, exercise stress test). Then empiric PPI trial for 8 weeks. | GERD accounts for ~30–60% of non-cardiac chest pain |
| Asthma exacerbation | Optimise asthma therapy first. Add PPI if nocturnal symptoms or acid taste. Consider pH monitoring. | Reflux may trigger bronchospasm via vagal reflex; PPI benefit modest |
| Dental erosions | Dental referral. Identify GERD vs bulimia vs dietary acid. PPI therapy + dental management. | Often first noted by dentist; check for eating disorders |
Barrett's Oesophagus Screening
Barrett's oesophagus is a metaplastic change in the distal oesophageal epithelium from squamous to intestinal-type columnar epithelium. It is a precursor for oesophageal adenocarcinoma (annual progression rate ~0.5%). Screening upper endoscopy is recommended in patients with chronic GERD (≥ 5 years) who have additional risk factors:
- Male sex
- Age ≥ 50 years
- Central (truncal) obesity (waist circumference > 102 cm men, > 88 cm women)
- White/Caucasian ethnicity
- Smoking history (current or former)
- Family history of Barrett's oesophagus or oesophageal adenocarcinoma (first-degree relative)
If Barrett's oesophagus is confirmed, surveillance intervals are determined by the length of the Barrett's segment and the presence/absence of dysplasia, per BSG/AGA guidelines. Referral to a gastroenterologist with expertise in Barrett's surveillance is recommended.
Long-Term Management & Referral
GERD is a chronic relapsing condition. Many patients require long-term acid suppression, but the goal should be the lowest effective dose for the shortest necessary duration. Regular review is essential to avoid indefinite PPI use without clear indication.
PPI Step-Down and Deprescribing Protocol
1
Review at 4–8 Weeks
Assess symptom response. If complete resolution, proceed to step-down. If partial, confirm diagnosis and adherence before escalating.
2
Step Down Dose
Reduce to half-dose PPI or switch to once-daily H₂RA (famotidine 20 mg). Maintain for 4 weeks and assess.
3
On-Demand / PRN Therapy
If symptoms controlled, shift to as-needed PPI or H₂RA use. Patients with NERD (non-erosive reflux disease) tolerate on-demand strategies well.
4
Complete Cessation Trial
After 3–6 months of on-demand therapy, consider stopping. Counsel on rebound hypersecretion (transient, resolves in 2–4 weeks). Resume if symptoms recur.
Indications for Long-Term PPI
Some patients have a genuine ongoing need for maintenance PPI therapy. Acceptable indications for long-term use include:
- Severe erosive oesophagitis (LA grade C/D) with relapse upon PPI cessation
- Confirmed Barrett's oesophagus (PPI may reduce progression risk)
- Peptic stricture requiring endoscopic dilatation (prevent recurrence)
- Patients on chronic anticoagulation, antiplatelet therapy, or corticosteroids with a history of peptic ulcer disease
- Zollinger-Ellison syndrome (high-dose PPI; specialist-managed)
Risks of Long-Term PPI Use
Long-term PPI safety considerations: While PPIs are generally safe, long-term use (≥ 1 year) has been associated with small but significant increases in: hypomagnesaemia (monitor serum Mg²⁺ annually), Clostridioides difficile infection (RR ~1.5), community-acquired pneumonia (slight increase in first 30 days of use), vitamin B₁₂ deficiency (especially elderly), bone fractures (hip, wrist, spine — modestly increased in elderly; ensure adequate calcium/vitamin D intake), and interstitial nephritis (rare; check eGFR periodically).
Indications for Gastroenterology Referral
| Indication | Urgency | MBS Item (if applicable) |
|---|---|---|
| Alarm features (dysphagia, bleeding, weight loss) | Urgent (category 2) — within 2 weeks | Endoscopy: MBS 30473 |
| PPI non-response (confirmed adherence, adequate trial, ≥ 8 weeks twice-daily) | Semi-urgent (category 3) | pH monitoring: MBS 12203; Manometry: MBS 12213 |
| Screening endoscopy for Barrett's (chronic GERD + risk factors) | Routine (category 3–4) | MBS 30473 |
| Confirmed Barrett's oesophagus — surveillance | Per dysplasia status (1–3 years) | MBS 30473 |
| Surgical referral for anti-reflux surgery | Routine — after objective GERD confirmation | Laparoscopic fundoplication: MBS 31575 |
| Recurrent peptic stricture | Semi-urgent | Endoscopic dilatation: MBS 30479 |
Anti-Reflux Surgery
Laparoscopic fundoplication (Nissen or Toupet) is the standard surgical intervention for GERD. It is indicated when:
- Objectively proven GERD (pH study positive, erosive oesophagitis, or Barrett's) with inadequate symptom control despite optimised PPI therapy
- Patient preference for definitive treatment over lifelong medication
- Medication intolerance or significant side-effects
- Large hiatal hernia with volume reflux or aspiration risk
- Young patients wishing to avoid decades of PPI use
Pre-operative assessment requires upper endoscopy, oesophageal manometry (to exclude achalasia and assess motility), and 24-hour pH monitoring (to confirm pathologic reflux). Patients should be counselled that ~20% resume PPI therapy within 10 years post-surgery, and side-effects include dysphagia (10–15% early), gas-bloat syndrome, and inability to vomit effectively.
Newer endoscopic therapies (transoral incisionless fundoplication [TIF], magnetic sphincter augmentation [LINX®]) are available in select Australian centres. Evidence is growing but long-term outcomes are less established than for laparoscopic fundoplication.
Annual Long-Term PPI Review Checklist
- ☐ Is the indication for ongoing PPI still valid?
- ☐ Attempt step-down or on-demand therapy if no high-risk indication
- ☐ Check serum magnesium (if ≥ 1 year use)
- ☐ Check vitamin B₁₂ (especially elderly)
- ☐ Check eGFR / renal function
- ☐ Ensure adequate calcium and vitamin D intake (elderly, fracture risk)
- ☐ Review concurrent medications for interactions
- ☐ Document lowest effective dose and plan for further deprescribing
Special Populations
Pregnancy
GERD affects up to 80% of pregnancies, especially in the 3rd trimester, due to progesterone-mediated LOS relaxation and mechanical displacement by the gravid uterus.
First-line: Lifestyle modifications + antacids/alginates. Avoid sodium bicarbonate-containing antacids (fluid overload) and magnesium trisilicate (theoretical fetal risk with prolonged use).
Second-line: Ranitidine is no longer available; famotidine 20 mg BD may be used (FDA category B; limited human data). Omeprazole and pantoprazole have the most extensive safety data among PPIs in pregnancy — use only if H₂RA/lifestyle measures fail.
Avoid lansoprazole (less safety data) and rabeprazole (animal data only). All PPIs are excreted in breast milk in small amounts — omeprazole is preferred if PPI is needed during breastfeeding.
Paediatrics
Physiologic reflux (posseting) is common in infants < 12 months and resolves spontaneously. No pharmacologic treatment is usually required.
Pathologic GERD in children warrants investigation: poor weight gain, feeding refusal, irritability, chronic cough, recurrent pneumonia, Sandifer syndrome.
PPI use: Omeprazole (0.7–3.5 mg/kg/day) or lansoprazole (0.5–2 mg/kg/day) for confirmed GERD. Duration limited to 4–8 weeks, then reassess. Initiation by or in consultation with a paediatrician or paediatric gastroenterologist is recommended.
Domperidone is NOT recommended for paediatric GERD (QT prolongation risk). Alginate-antacid suspension (Gaviscon Infant®) may be used in formula-fed infants under medical guidance.
Elderly (≥ 65 years)
GERD may present atypically in the elderly — cough, chest pain, or dysphagia may predominate over heartburn. A lower threshold for endoscopy is warranted.
PPI caution: Increased risk of C. difficile infection, hypomagnesaemia, fractures, B₁₂ deficiency, and drug interactions (clopidogrel, methotrexate). Use the lowest effective dose and review regularly.
Polypharmacy is common — review all medications for reflux exacerbation (CCBs, nitrates, anticholinergics, bisphosphonates). Ensure NSAIDs are co-prescribed with PPI if ongoing use required.
Renal Impairment
PPIs generally require no renal dose adjustment. However, long-term PPI use is associated with interstitial nephritis and hypomagnesaemia.
Monitoring: Check eGFR and serum magnesium (Mg²⁺) at least annually. If Mg²⁺ < 0.5 mmol/L, consider PPI dose reduction or switch.
Famotidine: Reduce dose by 50% if CrCl < 30 mL/min (e.g., 20 mg once daily instead of BD).
Patients on dialysis have altered drug clearance — specialist advice recommended for complex cases.
Hepatic Impairment
PPIs are hepatically metabolised via CYP2C19 and CYP3A4. In severe hepatic impairment (Child-Pugh C), clearance is significantly reduced.
Dose adjustment: Omeprazole — consider dose reduction in severe impairment. Esomeprazole — max 20 mg/day. Pantoprazole — max 20 mg/day in severe impairment. Rabeprazole — use with caution (limited data).
Patients with cirrhosis and ascites may have increased reflux due to raised intra-abdominal pressure. Fundoplication carries higher surgical risk in advanced liver disease.
Immunocompromised
Patients on immunosuppression (transplant recipients, biologics, chemotherapy) are at higher risk of C. difficile infection with PPI use and oesophageal candidiasis.
Candida oesophagitis: Consider in immunocompromised patients presenting with odynophagia. Diagnosed by endoscopy with biopsy; treated with fluconazole 200 mg PO/IV daily for 14–21 days.
CMV and HSV oesophagitis should be considered in severely immunosuppressed patients (e.g., post-transplant, advanced HIV) with oesophageal symptoms — endoscopy with biopsy and viral PCR is essential.
Aboriginal and Torres Strait Islander Health Considerations
Aboriginal and Torres Strait Islander Health
Quick Reference: GERD Management Summary
Typical GERD (no alarm features)
PPI once daily (e.g., omeprazole 20 mg)
4–8 weeks, then step down
+ lifestyle modifications
PPI non-response
Double-dose PPI (split BD) or switch PPI
8–12 weeks, then refer
Confirm adherence and timing; exclude functional heartburn
Alarm features
Do NOT empirically treat — investigate
Endoscopy within 2 weeks
Dysphagia, bleeding, weight loss, vomiting
Extra-oesophageal
PPI BD (e.g., omeprazole 20 mg BD)
8–12 weeks
Low response rate; pH monitoring if no improvement
Long-term maintenance
Lowest effective PPI dose or on-demand
Annual review
Monitor Mg²⁺, B₁₂, eGFR; deprescribe when able
📚 References
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