GERD and acid-related disorders
45-year-old on omeprazole for 14 months after a bout of heartburn.
No alarm features, symptom-free for a year. No NSAIDs, no antiplatelets.
What is the right conversation?
Therapeutics · Gastrointestinal
GERD and acid-related disorders
Therapeutic goals
- Symptom control with the least acid suppression that achieves it
- A stop date on every PPI that does not carry a continuing indication
- Red flags routed to assessment, not to stronger antacids
Patient factors that steer the choice
- Alarm features (dysphagia, bleeding, weight loss, anemia) → referral, not therapy escalation
- NSAID and antiplatelet exposure
- Duration of prior PPI use (rebound planning)
- Lifestyle contributors worth naming without moralizing
Major drug classes
Treatment approach
01Match intensity to pattern
Occasional heartburn: antacids/alginates or H2RA on demand. Frequent or erosive disease: a PPI course, properly timed before breakfast.
02Define the course
4-8 weeks for most indications, then reassess; continuing needs a reason (erosive esophagitis, Barrett's, chronic NSAID protection).
03Step down deliberately
Taper or alternate-day dosing, expect one to two weeks of rebound, backstop with on-demand antacids, and say all this in advance.
Monitoring
- Symptom response at 2-4 weeks
- The indication itself at every renewal
- Magnesium/B12 pragmatically in long-term use
Pearls
- The best deprescribing tool for PPIs is a sentence spoken at initiation: 'this is a course, not a subscription'.
- Bedtime PPIs underperform for a mechanistic reason. Pumps sleep too.
Choose the drug
Last reviewed 2026-08-15 · Principle-level content; jurisdiction-specific recommendations live in the cited guidelines: ACG Clinical Guideline: GERD (current) · Deprescribing.org PPI deprescribing algorithm