GERD Treatment According to the 2026 VNAGE Guideline: Key Recommendations

Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder with a broad range of clinical presentations. Its management therefore requires more than simply selecting an acid-suppressive medicine. The clinical approach needs to consider the patient’s symptoms, disease phenotype, response to treatment, adherence, lifestyle factors, and relevant overlapping conditions.

In 2026, the Vietnam Association of Gastroenterology (VNAGE) published a guideline on the management of gastroesophageal reflux disease. The guideline provides recommendations covering lifestyle modification, proton pump inhibitors (PPIs), alginate therapy, potassium-competitive acid blockers (P-CABs), refractory GERD, extra-esophageal manifestations, overlapping disorders of gut-brain interaction, and anti-reflux endoscopic or surgical interventions.

This article summarizes the key treatment recommendations from the 2026 VNAGE guideline, including the level of evidence, strength of recommendation, and degree of expert consensus.

Individualized management of GERD
Lifestyle and dietary modification
The role of PPIs in GERD treatment
Alginate therapy in mild-to-moderate GERD
P-CABs and acid suppression
Managing refractory GERD
Extra-esophageal manifestations
GERD and disorders of gut-brain interaction
When to consider anti-reflux procedures
Summary of the 10 VNAGE 2026 recommendations
Key clinical takeaway

1. Individualized Management of GERD

One of the central principles of the 2026 VNAGE guideline is that GERD treatment should be individualized.

The guideline recommends combining dietary and lifestyle modification with optimized medical therapy according to the patient’s clinical situation. Anti-reflux endoscopic or surgical procedures should only be considered in appropriately selected patients.

This recommendation has a high level of evidence and a strong recommendation, with 92.9% of the expert panel fully agreeing and 7.1% agreeing with some concerns.

The emphasis on individualized management is important because GERD does not present identically in every patient. Treatment decisions should therefore be guided by the clinical characteristics and response of the individual patient rather than by a single standardized approach.

2. Dietary and Lifestyle Modification

Pharmacological treatment is only one component of GERD management.

The 2026 VNAGE guideline recommends dietary and lifestyle modification to help reduce reflux symptoms. Specifically, weight reduction and elevating the head of the bed during sleep are included in the recommendation.

This recommendation has a moderate level of evidence and a strong recommendation. The expert consensus was 71.4% fully agreeing, 21.4% agreeing with some concerns, and 7.1% agreeing with major concerns.

These measures should be considered as part of an overall management strategy rather than as a universal substitute for pharmacological treatment when medication is clinically indicated.

3. The Role of PPIs in GERD Treatment

Proton pump inhibitors (PPIs) remain an important component of GERD treatment in the 2026 VNAGE guideline.

For patients with endoscopically confirmed erosive reflux disease, the guideline recommends a standard-dose PPI course for 8 weeks to promote healing of the esophageal mucosa and reduce symptoms.

This recommendation has a high level of evidence and a strong recommendation, with 100% of the expert panel fully agreeing.

For patients with non-erosive reflux disease (NERD), the guideline recommends a standard-dose PPI course for 4–8 weeks. This recommendation also carries a high level of evidence and a strong recommendation.

The distinction between erosive reflux disease and NERD is clinically relevant because treatment recommendations are not necessarily identical across different GERD phenotypes.

4. Alginate Therapy in Mild-to-Moderate GERD

For patients with mild-to-moderate GERD, the 2026 VNAGE guideline recommends beginning with dietary and lifestyle modification, followed by alginate therapy for symptom relief.

If symptoms persist, treatment with a PPI alone or in combination with alginate may be considered.

This recommendation has a moderate level of evidence and a strong recommendation. The expert consensus was 75% fully agreeing and 25% agreeing with some concerns.

The original source describes alginate as a physical barrier-based approach to reflux management. However, for a clinical website article, it is important not to extend the guideline recommendation into unsupported claims about comparative speed or superiority unless those claims are supported by separate evidence.

5. P-CABs and Acid Suppression

Potassium-competitive acid blockers (P-CABs) are also addressed in the 2026 VNAGE guideline.

The guideline states that P-CABs may be considered for acid suppression in the management of GERD.

This recommendation has a moderate level of evidence and a strong recommendation. However, the degree of consensus was more variable than for some of the other recommendations: 60.7% fully agreed, 32.1% agreed with some concerns, and 7.1% agreed with major concerns.

Therefore, the recommendation should not be interpreted as meaning that P-CABs automatically replace PPIs for all patients. Their use should be considered within the clinical context and treatment strategy for the individual patient.

6. Managing Refractory GERD

Persistent symptoms despite PPI therapy are an important clinical challenge.

For patients with refractory GERD, the VNAGE guideline recommends evaluating optimization of medical treatment before considering dose escalation, switching to another PPI, or adding adjunctive therapies.

This includes assessing:

Lifestyle modification
Treatment adherence
Optimization of existing medical therapy

The recommendation has a high level of evidence and a strong recommendation. Expert consensus was 82.1% fully agreeing, 10.7% agreeing with some concerns, and 7.1% agreeing with major concerns.

This approach is clinically important because persistent symptoms during PPI therapy should not automatically be interpreted as a reason to escalate treatment. The treatment strategy should first be reviewed systematically.

7. Extra-Esophageal Manifestations of GERD

GERD may be associated with symptoms outside the esophagus. However, establishing whether such symptoms are actually related to GERD requires careful clinical assessment.

The 2026 VNAGE guideline recommends PPI therapy for patients with extra-esophageal manifestations accompanied by typical GERD symptoms.

In contrast, when extra-esophageal symptoms occur without typical GERD symptoms, additional functional diagnostic testing should be performed to confirm GERD before initiating PPI therapy.

This recommendation has a moderate level of evidence and a strong recommendation, with 78.6% of the panel fully agreeing, 17.9% agreeing with some concerns, and 3.6% agreeing with major concerns.

This distinction helps avoid attributing nonspecific extra-esophageal symptoms to GERD without sufficient diagnostic support.

8. GERD and Disorders of Gut-Brain Interaction

Another consideration in GERD management is the overlap between GERD and disorders of gut-brain interaction (DGBIs).

The 2026 VNAGE guideline recommends that, in patients with GERD overlapping with other DGBIs, treatment should include a combination of acid suppression and adjunctive pharmacological therapies.

This recommendation has a moderate level of evidence and a strong recommendation.

The consensus distribution was:

75% fully agree
14.3% agree with some concerns
3.6% agree with major concerns
3.6% disagree
3.6% strongly disagree

This recommendation highlights the importance of considering overlapping gastrointestinal conditions when symptoms are not adequately explained or controlled by acid suppression alone.

9. When Should Anti-Reflux Endoscopic or Surgical Procedures Be Considered?

Anti-reflux endoscopic or surgical procedures are not recommended as a routine next step for every patient with GERD.

According to the 2026 VNAGE guideline, these interventions may be considered in appropriately selected patients who have objective evidence of GERD and continue to experience troublesome typical reflux symptoms despite optimized medical treatment.

The recommendation has a low level of evidence, although the strength of recommendation is strong.

The expert consensus was more variable than for several pharmacological recommendations:

64.3% fully agree
14.3% agree with some concerns
10.7% agree with major concerns
3.6% disagree
7.1% strongly disagree

This reinforces the importance of appropriate patient selection and objective evidence when considering procedural treatment.

10. Summary of the 10 VNAGE 2026 Recommendations

The following table follows the structure of the recommendation table in the source document, including the level of evidence, strength of recommendation, and expert consensus.

No.	Recommendation	Level of evidence	Strength of recommendation	Expert consensus
1	GERD treatment, including dietary and lifestyle modification combined with optimized medical therapy, should be individualized. Anti-reflux endoscopic or surgical procedures should only be considered in appropriately selected cases.	High	Strong	Fully agree 92.9%; agree with some concerns 7.1%
2	Dietary and lifestyle modification, including weight reduction and elevation of the head of the bed during sleep, is recommended to reduce reflux symptoms.	Moderate	Strong	Fully agree 71.4%; agree with some concerns 21.4%; agree with major concerns 7.1%
3	PPIs are a cornerstone of GERD treatment. A standard-dose PPI course for 8 weeks is effective in promoting esophageal mucosal healing and reducing symptoms in patients with endoscopically confirmed erosive reflux disease.	High	Strong	Fully agree 100%
4	Patients with mild-to-moderate GERD should begin with dietary and lifestyle modification, followed by alginate therapy for symptom relief. If symptoms persist, PPI monotherapy or combination therapy with alginate may be considered.	Moderate	Strong	Fully agree 75%; agree with some concerns 25%
5	A standard-dose PPI for 4–8 weeks is recommended for non-erosive reflux disease (NERD).	High	Strong	Fully agree 82.1%; agree with some concerns 17.9%
6	PPI therapy is recommended for patients with extra-esophageal manifestations accompanied by typical reflux symptoms. In patients with extra-esophageal symptoms without typical GERD symptoms, additional functional diagnostic testing should be performed to confirm GERD before initiating PPI therapy.	Moderate	Strong	Fully agree 78.6%; agree with some concerns 17.9%; agree with major concerns 3.6%
7	In patients with refractory GERD, optimization of medical treatment, including lifestyle modification and assessment of adherence, should be evaluated before considering dose escalation, switching to another PPI, or adding adjunctive therapies.	High	Strong	Fully agree 82.1%; agree with some concerns 10.7%; agree with major concerns 7.1%
8	P-CABs may be considered for acid suppression in the management of GERD.	Moderate	Strong	Fully agree 60.7%; agree with some concerns 32.1%; agree with major concerns 7.1%
9	Anti-reflux endoscopic or surgical procedures may be considered in appropriately selected patients with objective evidence of GERD who continue to experience troublesome typical reflux symptoms despite optimized medical treatment.	Low	Strong	Fully agree 64.3%; agree with some concerns 14.3%; agree with major concerns 10.7%; disagree 3.6%; strongly disagree 7.1%
10	In patients with GERD overlapping with other disorders of gut-brain interaction (DGBIs), treatment should include a combination of acid suppression and adjunctive pharmacological therapies.	Moderate	Strong	Fully agree 75%; agree with some concerns 14.3%; agree with major concerns 3.6%; disagree 3.6%; strongly disagree 3.6%

11. Key Clinical Takeaways

The 10 recommendations provide several important principles for GERD management.

Treatment should be individualized

The guideline does not support a single treatment pathway for every patient. Clinical presentation, GERD phenotype, treatment response, adherence, and overlapping conditions all need to be considered.

Lifestyle modification remains relevant

Weight reduction and elevation of the head of the bed are included in the guideline recommendations and should be considered as part of comprehensive GERD management.

PPIs remain an important treatment option

The guideline supports standard-dose PPI therapy for specific GERD phenotypes, including an 8-week course for endoscopically confirmed erosive reflux disease and 4–8 weeks for NERD.

Alginate has a defined role in symptom management

For mild-to-moderate GERD, the guideline places alginate after lifestyle and dietary modification, with PPI therapy considered when symptoms persist.

P-CABs provide an additional acid-suppression option

P-CABs may be considered for acid suppression, but the recommendation should not be interpreted as a universal replacement for PPI therapy.

Refractory GERD requires reassessment

Before escalating treatment, clinicians should assess adherence and optimize the existing management strategy.

Extra-esophageal symptoms require diagnostic consideration

GERD should not automatically be assumed to be the cause of extra-esophageal symptoms, particularly when typical GERD symptoms are absent.

Overlapping conditions may require a broader treatment approach

The presence of DGBIs may influence the management strategy and may require adjunctive pharmacological treatment in addition to acid suppression.

Conclusion

The 2026 VNAGE guideline on GERD management provides a structured approach to the diagnosis and treatment of gastroesophageal reflux disease in the Vietnamese clinical context.

A central message is the importance of individualized treatment, combining lifestyle modification with appropriate medical therapy and reserving invasive interventions for appropriately selected patients.

PPIs remain an important component of pharmacological treatment, while alginate therapy has a role in mild-to-moderate GERD and P-CABs may be considered for acid suppression. For patients with persistent symptoms, careful assessment of adherence and treatment optimization should precede escalation of therapy.

The guideline also highlights the importance of distinguishing typical GERD symptoms from extra-esophageal manifestations and considering overlapping disorders of gut-brain interaction.

Overall, the recommendations reinforce a practical principle in clinical care: effective GERD management is not simply about choosing an acid-suppressive drug, but about selecting an appropriate treatment strategy for the individual patient.

References

Dao HV, Mai BH, Dao LV, et al. Vietnam Association of Gastroenterology (VNAGE) guideline on the management of gastroesophageal reflux disease. Frontiers in Medicine. 2026;13:1890726.

Medical disclaimer: This article is intended for medical and clinical education purposes. It does not replace professional medical assessment, diagnosis, or treatment decisions for individual patients.

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