This algorithm is used for patients with gastro-oesophageal reflux disease (GORD) who are taking a proton pump inhibitor (PPI).

It has two major components, which are shown on either the left or the right side of the algorithm.

On the left side, the algorithm addresses patients with well-controlled GORD symptoms.

On the right side, the algorithm addresses patients with GORD symptoms that are not well controlled.

Starting at the top of the algorithm, there are two groups of patients. One group has been on an initial PPI for 4 to 8 weeks for suspected GORD. The other group has been on a PPI long term for confirmed GORD.

Both of these patient groups feed into a box titled ‘Review patient on PPI’.

The algorithm then splits into two components, depending on whether symptoms are well controlled or not.

If GORD symptoms are well controlled, an arrow leads to a box titled ‘Discuss options and implement stepping down to lowest effective dose, or stopping’. A dashed arrow also leads back from this box in the opposite direction, as a reminder of the need for ongoing patient review even when symptoms are well controlled.

Within the box titled ‘Discuss options and implement stepping down to lowest effective dose, or stopping’ there are three hexagons that are interconnected with two-way arrows.

From left to right, these hexagons are labelled ‘Use low dose/frequency of PPI regularly’, ‘Use PPI on demand (as required)’ and ‘Stop PPI’.

If symptoms are well controlled for 4 to 8 weeks, the arrows are followed to the right.

If symptoms are not well controlled, the arrows are followed to the left.

Beneath these three hexagons, there is a note to ‘Manage rebound acid hypersecretion as required’. The recommendations for this note are to ‘Gradually reduce the dose before stopping PPI to reduce risk’ and ‘Treat mild rebound symptoms with antacids or H2 receptor antagonists’.

Moving back up to the box titled ‘Review patient on PPI’, if GORD symptoms are not well controlled, an arrow leads to a box advising to ‘Confirm adherence’ and ‘Consider endoscopy (+/– referral to specialist)’. This then splits into two possible directions.

If endoscopy indicates another diagnosis, an arrow leads to a box that advises ‘Manage new diagnosis appropriately’.

If endoscopy supports GORD diagnosis, an arrow leads to a box that advises ‘Prescribe high-dose PPI’.

If symptoms are not well controlled with a high-dose PPI, this in turn leads to another box that advises ‘Refer to specialist’.

If symptoms are well controlled for 4 to 8 weeks with a high-dose PPI, the ‘Prescribe high-dose PPI’ box leads back via a dashed arrow to the ‘Review patient on PPI’ box, as a reminder of the need for ongoing patient review even when symptoms are well controlled.