Gastro-oesophageal reflux disease (GORD) is defined as reflux or heartburn symptoms that are:

• frequent (two or more times per week) OR
  
• severe and significantly impact on your life.
  

Reflux occurs when stomach acid leaks from the stomach and moves up into the oesophagus (food pipe). Sometimes you can feel the stomach acid coming up into your mouth causing a sour, unpleasant taste. You may also have a burning chest pain or discomfort after eating, called heartburn.

Reflux and heartburn are common conditions, and over-the-counter medicines can bring relief. Ask your pharmacist about the most appropriate over-the-counter medicine for you.

If your symptoms are particularly regular or severe, talk to your health professional. You may have GORD and need a different treatment.

GORD is diagnosed based on symptoms – frequent or severe reflux or heartburn.

If you also have any of the following, your health professional may refer you for an examination called an endoscopy to determine whether there is another cause of your symptoms:

• difficulty swallowing
  
• painful swallowing
  
• unexpected weight loss
  
• persistent vomiting
  
• dark, tarry or sticky faeces.
  

Making some lifestyle changes, such as avoiding certain foods and drinks that may trigger your reflux, can often help reduce reflux symptoms.

If you have mild and infrequent symptoms (not GORD), these changes may be all that you need.

If you have GORD, your health professional may prescribe a 4–8-week course of a medicine called a proton pump inhibitor (PPI). A PPI reduces the amount of acid produced in the stomach and is effective at treating reflux symptoms. 

A PPI medicine is taken once a day 30–60 minutes before a meal.

• If you mostly have symptoms during the day, you should take the PPI before breakfast.
  
• If you mostly have symptoms at night, you should take the PPI before your evening meal.
  

After completing an initial course of PPIs, many people can reduce the amount of medicine they take, or stop taking medicine, and still maintain control of their symptoms.

Making changes to your lifestyle may help reduce your reflux symptoms, even while you are taking medicine for GORD. Not all changes will work for all people. Your health professional can help you to decide what may work best for you.

Changes that could be helpful include:

• losing weight, if your health professional suggests this is necessary – even modest weight loss can help, and studies have shown that overweight people experience a greater relief from symptoms the more weight they lose
  
• stopping smoking – a study of people taking a regular medicine for reflux found that stopping smoking almost halved the severity of their reflux symptoms; the improvements were mostly among people of normal weight
  

• cutting back on alcohol – alcohol may trigger reflux symptoms in some people
• avoiding certain foods and drinks that trigger your reflux symptoms – examples include fatty foods, chocolate, spicy foods and coffee; different people find different foods and drinks trigger their symptoms, so only avoid those that affect you so that you don’t restrict your diet unnecessarily
  

• raising the head of your bed (by placing blocks underneath the bedhead), sleeping on a wedge pillow or wedging up your mattress by 20 cm – this can help if you have reflux symptoms at night and they disrupt your sleep
  
• avoiding lying down after eating

• eating smaller meals
  
• avoiding eating 2–3 hours before bedtime
  
• avoiding eating before vigorous exercise.
  

After completing an initial course of low or standard dose PPIs, many people can reduce the amount of medicine they take and still maintain control of their symptoms. Up to 6 out of 10 people can also stop taking PPIs without their symptoms returning.

For these reasons, your health professional may ask you to return for a review after you have completed your initial course of treatment. If your symptoms are well controlled, your health professional may suggest trying to reduce your PPI medicine by:

• lowering your PPI dose
  
• taking your PPI on alternate days
  
• taking your PPI only when you get symptoms
  
• stopping your PPI.
  

Some people with GORD need to continue taking PPIs over a longer period. Also, there are other conditions you may have that need ongoing PPI treatment.

Remember that lifestyle changes remain an important part of managing GORD. After you have stopped taking a PPI, lifestyle changes become even more important in controlling your reflux symptoms.

Rebound acid hypersecretion

If PPIs are stopped suddenly, reflux symptoms may return for around 4–5 days because of what is known as rebound acid hypersecretion. This occurs when the stomach has become used to a PPI and starts producing more acid. Some over-the-counter medicines can help relieve symptoms while the stomach readjusts to no longer needing a PPI.

To reduce the risk of rebound acid hypersecretion, your health professional may ask you to gradually lower your PPI dose before stopping. This may mean taking a lower dose of PPI medicine, or taking it only on alternate days. Your reflux symptoms may change over time, so the dose of PPI you need may also change. Your health professional can help you to manage this.

PPIs have been used for many years by millions of people. If they are used appropriately, the benefits of taking these medicines are greater than the possible risk of side effects.

Some common side effects include headache, nausea, vomiting and diarrhoea.

Researchers have studied possible more serious side effects of taking PPIs, including kidney disorders (acute interstitial nephritis), bone fractures, certain infections (Clostridium difficile infection), low magnesium, low vitamin B₁₂ and pneumonia. However, from these studies it was not clear whether PPIs were the cause of these side effects.

Even though it is not clear if PPIs can cause such serious side effects, it is not a good idea to stay on any medicine for longer than you need to. If your GORD is under control, ask your health professional whether you can make a plan to lower your dose or stop your PPI medicine.

• Choosing Wisely Australia 5 questions you can ask your health professional and tips for your next healthcare appointment.
  
• The NPS MedicineWise Patient Action Plan can help you to manage the treatment of your reflux.
  
• The Choosing Wisely Australia fact sheet Heartburn and reflux: Manage your medicine has more information on heartburn and its treatment.
  

• Australian Medicines Handbook. Proton pump inhibitors. Adelaide: AMH Pty Ltd, 2017. (accessed 31 August 2021).
  
• Gastrointestinal Expert Group. Therapeutic Guidelines: disorders of the oesophagus. West Melbourne: Therapeutic Guidelines Ltd, 2019. (accessed 31 August 2021).
  
• Haastrup P, Paulsen MS, Begtrup LM, et al. Strategies for discontinuation of proton pump inhibitors: a systematic review. Fam Pract 2014;31:625-30. 
  
• Kang JH-E, Kang JY. Lifestyle measures in the management of gastro-oesophageal reflux disease: clinical and pathophysiological considerations. Ther Adv Chronic Dis 2015;6:51-64. 
  
• Lødrup AB, Reimer C, Bytzer P. Systematic review: Symptoms of rebound acid hypersecretion following proton pump inhibitor treatment. Scand J Gastroenterol 2013;48:515-22. 
  
• Maes ML, Fixen DR, Linnebur SA. Adverse effects of proton-pump inhibitor use in older adults: a review of the evidence. Ther Adv Drug Saf 2017;8:273-97. 
  
• Malfertheiner P, Kandulski A, Venerito M. Proton-pump inhibitors: understanding the complications and risks. Nat Rev Gastroenterol Hepatol 2017;14:697. 
  
• Ness-Jensen E, Lindam A, Lagergren J, et al. Tobacco smoking cessation and improved gastroesophageal reflux: a prospective population-based cohort study. The HUNT study. Am J Gastroenterol 2014;109:171-7. 
  
• Prescribing PPIs. Drug Ther Bull 2017;55:117-20.