With all these drugs to choose from, how do doctors decide which is the right acid reflux treatment for you? This is where the ‘guidelines’ from NICE (the National Institute for Clinical Excellence) are so helpful.

NICE recommends either a ’step up’ or a ’step down’ approach, depending on the severity of your acid reflux disease. There are 5 five levels, starting with the mildest treatment (antacids/alginates) through H2 antagonists, to rising doses of PPIs. For example, if endoscopy has shown that you have ulcers in your esophagus or Barren’s esophagus, you will start on the highest ‘healing’ dose of a PPI - level 5. The dose can eventually be cut down once the symptoms have improved, to a level that continues to keep you symptom-free.

On the other hand, if you have mild symptoms and no need for endoscopy, you may be started on level 1, with an antacid-alginate combination and advised on lifestyle. If this does not work, your doctor may add an H2 antagonist - level 2.

Depending on your progress after that, you will pass up or down the scale. All patients should have their own ‘treatment plan’ that guides them on how to manage their own symptoms, and this can often be stopped when their esophagus eventually heals and the symptoms disappear.

However, the fact that you are able to stop the treatment doesn’t mean that you can now stop going to your doctor.

Most people with gastro-esophageal reflux disease (GERD) require long term management. The guiding principle for long term management is to step down to the treatment that is least costly but still effective in controlling your GERD and acid reflux symptoms.

Finding the right level of management may take time in some patients. Patients returning with a relapse after a trial without treatment should be restarted on the initially successful therapy and then have treatment stepped down as appropriate. For patients who require only intermittent short courses of antisecretory (acid-lowering) therapy, it may be more effective to give a proton pump inhibitor at full dose than to titrate treatment up from either half dose of PPI or a standard dose of H2 receptor antagonist.

By optimizing the treatment in these ’steps’, endoscopy is kept to a minimum. If a particular acid reflux treatment successfully controls a patient’s symptoms, the doctor can be assured that the esophagitis has healed, and there is no need for further endoscopies.

Even when the patient needs to continue on long-term PPIs because of severe esophagitis (Los Angeles stages (C) and (D)), repeat endoscopy is not always needed, as it is safe to assume that if the GERD symptoms are absent, the esophagitis has healed. On the other hand, patients in these categories must have repeat endoscopies if they still have symptoms despite standard daily doses of PPIs.

The groups of patients who must be kept on continuous treatment include:

Patients with ulcers in the esophagus that have been induced by an NSAID and who have no choice but to continue with it because they have chronic pain (such as from arthritis). They should remain on maintenance doses of PPIs (level 4).

Patients with severe GERD, such as Barren’s esophagus or an endoscopy-proven ulcer, should also remain on maintenance doses of a PPI (level 4).

Patients whose very severe acid reflux disease has been complicated in the past by stricture, ulcers and hemorrhage should be left on full doses of PPIs (level 5).

‘Prokinetic’ drugs, designed to speed up the passage of food from stomach to duodenum, such as metoclopramide (Maxolon, Gastro-bid) can be added, if needed, to help prevent bloating.