By vgreene, 26 May, 2015 If nocturnal sx, sleep disturbance, &/or variable schedules: consider dose-timing<sup>19</sup> adjustment &/or bid dosing [S/L]. Bedtime H2RA tx can be added prn to daytime PPI in pts w/ nighttime sx, but tachyphylaxis may occur after several wks [C/L]
By vgreene, 26 May, 2015 Increase PPI dosing<sup>19</sup> to bid or consider a switch to a different PPI<sup>20</sup> [C/L]
By vgreene, 26 May, 2015 If refractory w/ evidence of ongoing reflux on eval: consider additional antireflux tx (eg, TLESRI drug or surgery)<sup>16</sup> [C/L]
By vgreene, 26 May, 2015 If abnl amounts of nonacid reflux on PPI tx w/ good symptom correlation on esophageal pH-impedance monitoring: consider for surgery
By vgreene, 26 May, 2015 If objective documentation of symptomatic reflux despite optimal PPI tx: consider baclofen<sup>17</sup> trial 5-20 mg tid
By vgreene, 26 May, 2015 If extraesophageal sx<sup>13</sup> persist despite PPI optimization: concomitant evaluation by ENT, pulmonary, and allergy specialists<sup>14</sup> [S/L]; if refractory after these evals negative: ambulatory reflux<sup>15</sup> monitoring [S/L]
By vgreene, 26 May, 2015 If typical/dyspeptic sx PPI-refractory: upper endoscopy<sup>13</sup> to r/o non-GERD etiologies [C/L]; if endoscopy negative: ambulatory reflux monitoring [S/L]; if tests negative, unlikely to have GERD, so discontinue PPI [S/L]
