A 52-year-old man with a 10-year history of GERD presents with persistent symptoms despite lifestyle modifications. Upper endoscopy reveals erosive esophagitis (Los Angeles Grade C). He requires long-term acid suppression. Which drug is the first-line choice for healing and maintenance therapy?

Explanation

## Drug of Choice for Erosive GERD **Key Point:** Proton pump inhibitors (PPIs) are the gold standard for healing erosive esophagitis and long-term maintenance therapy in GERD. ### Why Omeprazole (PPI) is Superior Omeprazole and other PPIs provide: - **Profound acid suppression:** Inhibit the final step of gastric acid secretion (H+/K+-ATPase), reducing intragastric pH to <2 for >18 hours daily - **Healing rates:** 80–90% healing of erosive esophagitis within 4–8 weeks (vs. 50–60% with H2 blockers) - **Symptom relief:** Superior to H2 blockers in controlling breakthrough symptoms - **Long-term efficacy:** Maintain remission in >90% of patients on maintenance therapy ### Comparison with Other Options | Feature | PPI (Omeprazole) | H2 Blocker (Famotidine) | Antacid (Al(OH)₃) | |---------|------------------|------------------------|-------------------| | **Acid suppression** | Profound (pH >4 for 18+ hrs) | Moderate (pH 3–4) | Temporary (pH 5–6) | | **Healing erosive esophagitis** | 80–90% in 4–8 weeks | 50–60% in 8–12 weeks | Poor | | **Maintenance therapy** | Excellent | Moderate | Not suitable | | **Duration of action** | 24–48 hours | 12 hours | 30 min–2 hours | **High-Yield:** PPIs are preferred over H2 blockers for: - Erosive esophagitis (Grade B or C) - Barrett's esophagus - Long-term maintenance therapy - Zollinger–Ellison syndrome **Clinical Pearl:** H2 blockers (famotidine, ranitidine) are useful only for mild, non-erosive GERD or as adjunctive therapy; they cannot heal erosive disease reliably. **Warning:** Antacids provide only symptomatic relief and are not suitable for healing erosive esophagitis—they have a duration of action of 30 minutes to 2 hours.