## First-Line Treatment of GERD **Key Point:** Proton pump inhibitors (PPIs) are the gold-standard first-line agents for long-term management of GERD, particularly in patients with persistent symptoms or erosive disease. ### Rationale for PPI Selection **High-Yield:** PPIs provide superior acid suppression compared to H₂ blockers: - Inhibit the final common pathway of gastric acid secretion (H⁺/K⁺-ATPase pump) - Achieve >90% acid suppression within 24 hours - More effective for healing erosive esophagitis and preventing relapse - Standard dosing: omeprazole 20 mg once daily (or 40 mg for severe disease) ### Comparison of GI Acid-Suppressant Agents | Agent Class | Mechanism | Acid Suppression | Duration | Use | |---|---|---|---|---| | **PPI (Omeprazole)** | H⁺/K⁺-ATPase inhibition | >90% | 24–72 hours | First-line GERD, erosive disease | | **H₂ Blocker (Ranitidine)** | H₂ receptor antagonism | 60–70% | 8–12 hours | Mild GERD, acute relief | | **Antacid (Al(OH)₃)** | Neutralization | Immediate but brief | 30–60 min | Symptomatic relief only | | **Cytoprotectant (Sucralfate)** | Mucosal coating | None | 6 hours | Adjunct; not for acid suppression | **Clinical Pearl:** H₂ blockers (ranitidine) are less potent and have shorter duration of action; they are reserved for mild GERD or as adjuncts. Antacids provide only temporary relief and are unsuitable for chronic management. **Warning:** Sucralfate does not suppress acid — it protects the mucosa. It is not a first-line agent for GERD. ### Evidence-Based Guideline ACG (American College of Gastroenterology) and international guidelines recommend PPI monotherapy as first-line for: - Erosive esophagitis - Chronic GERD with persistent symptoms - Long-term maintenance therapy [cite:KD Tripathi 8e Ch 48]
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