Gastro-oesophageal reflux disease

Key NICE recommendations on management

Please be aware that some of the following indications for medications may not be licensed by the manufacturer (i.e., the use of the medication is ‘off-label’). Refer to the full NICE guideline and your local drug formulary for further information when prescribing.

This summary covers recommendations for investigating and managing gastro-oesophageal reflux disease in adults (aged 18 years and over).

Referral guidance for endoscopy

The NICE guideline summarised here (i.e., Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management [CG184]) does not make comprehensive recommendations about referral for endoscopy in people who present with ‘reflux-like’ symptoms, but provides the following guidance:​

• Refer people immediately (same day) to a specialist if they present with ‘reflux-like’ symptoms together with significant acute gastrointestinal bleeding

• Review medications for possible causes of symptoms (e.g., calcium antagonists, nitrates, theophyllines, bisphosphonates, non-steroidal anti-inflammatory drugs, corticosteroids). Suspend non-steroidal anti-inflammatory drug use in people needing referral for endoscopy

• Consider the possibility of cardiac or biliary disease within differential diagnoses

• If the person has had a previous endoscopy and does not have any new alarm signs, consider continuing management according to previous endoscopic findings.

For more information about alarm signs and when to refer people to specialists when they present with symptoms that could be caused by cancer, see the NICE guideline Suspected cancer: recognition and referral (NG12).​

Non-pharmacological management

Offer simple lifestyle advice including:

• Healthy eating, weight reduction and smoking cessation

• Avoiding known precipitants of their symptoms where possible (e.g., alcohol, coffee, chocolate, fatty foods)

• Raising the head of the bed, and having a main meal well before going to bed.

Provide access to educational materials to support care. Psychological therapies (e.g., cognitive behavioural therapy, psychotherapy) may reduce symptoms in the short-term.

Pharmacological treatment for uninvestigated ‘reflux-like’ symptoms

Offer people with uninvestigated ‘reflux-like’ symptoms:​

• Empirical full-dose proton-pump inhibitor (PPI) therapy for 4 weeks

• 'Test and treat' for Helicobacter pylori (leave a 2-week washout period after PPI use before testing with a breath test or a stool antigen test). See the NICE guideline for more information on Helicobacter pylori testing and eradication treatment.

Offer H₂ receptor antagonist therapy if the response to a PPI is inadequate.

If symptoms return after initial care strategies, step down PPI therapy to the lowest dose needed to control symptoms, and discuss using the treatment on an ‘as-needed’ basis.

Offer annual review for people requiring long-term symptom management, and encourage them to try stepping-down or stopping treatment (unless there is an underlying condition or comedication that needs continuing treatment).

• Advise that it may be appropriate to return to self-treatment with antacid and/or alginate therapy (prescribed or purchased over-the-counter and taken ‘as-needed’).

Pharmacological treatment for endoscopically determined gastro-oesophageal reflux disease (GORD)

In the NICE guideline, GORD refers to endoscopically determined oesophagitis or endoscopy-negative reflux disease.

For severe oesophagitis, offer initial treatment with a full-dose PPI for 8 weeks.​

• If this fails to heal the oesophagitis, consider a high dose of the initial PPI, or switching to another PPI at full-dose or high-dose (considering tolerability of the initial PPI).

• Offer a full-dose PPI long-term as maintenance treatment. If severe oesophagitis fails to respond to the maintenance PPI, review the person and consider switching to another PPI at full-dose or high-dose, and/or seek specialist advice.

• Note that what constitutes “full-dose” and “high-dose” PPI treatment may differ for severe oesophagitis. See Appendix of the NICE guideline for further information.

For GORD without severe oesophagitis, offer a full-dose PPI for 4 or 8 weeks.

• If symptoms recur after initial treatment, offer a PPI at the lowest effective dose.

• Discuss with the person how to use treatment ‘as-needed’ to manage symptoms.

Offer H₂ receptor antagonist therapy if the response to a PPI is inadequate.

People who have oesophageal stricture dilatation should stay long-term on a full-dose PPI.

Referral to a specialist service

Consider referral to a specialist service for adults:

• Of any age with gastro-oesophageal symptoms that are non-responsive to treatment or unexplained (i.e., have not led to a diagnosis after initial primary care assessment)

• With suspected GORD who are considering surgical management (e.g., laparoscopic fundoplication, which can be considered for those whose symptoms respond to acid suppression therapy, but who cannot tolerate or do not wish to continue this)

• With Helicobacter pylori that has not responded to second-line eradication therapy.

Barrett's oesophagus

Do not routinely offer endoscopy to diagnose Barrett's oesophagus, but consider it if the person has GORD.​

• Discuss the person's preferences and consider their individual risk factors (e.g., long duration or increased frequency of symptoms, previous oesophagitis, previous hiatus hernia, oesophageal ulcers or stricture, or male gender).

Endoscopic surveillance for progression to cancer should be considered for people who have a diagnosis of Barrett's oesophagus (confirmed by endoscopy and histopathology), taking into account the presence of dysplasia, individual preference and the person's risk factors (e.g., male gender, older age and the length of the Barrett's oesophagus segment).

• The harms of surveillance may outweigh the benefits where the risk of progression to cancer is low (e.g., those with stable non-dysplastic Barrett's oesophagus).

© NICE (2019) All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England https://www.nice.org.uk/terms-and-conditions#notice-of-rights . All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.