Nat. Rev. Gastroenterol. Hepatol. doi:10.1038/nrgastro.2016.50 Figure 4 Current management algorithm for typical rGERD symptoms in the opinion of the authors, accounting for access to MII-pH monitoring Figure 4 | Current management algorithm for typical rGERD symptoms in the opinion of the authors, accounting for access to MII-pH monitoring. Endoscopic treatments have not been added to the algorithm because of inconclusive evidence on their efficacy in patients with rGERD. *Typical GERD symptoms are heartburn and/or regurgitation not located in the epigastrium (dyspepsia) or the throat area. ‡Baclofen is started at 5 mg three times a day before meals, and increased to 10 mg three times a day after 1 week. Therapeutic effectiveness can be evaluated after one month. Up-titration to 20 mg three times a day can be considered in case of good tolerance and partial efficacy of lower doses. §A neuromodulator can be a tricyclic antidepressant, for example, nortriptyline 25–50 mg in the evening, or a selective serotonin reuptake inhibitor, for example, citalopram 20 mg or fluoxetine 20 mg in the morning. ||Baclofen in the evening is started at 5 mg at bedtime, and can be increased to 10 mg or 20 mg. Therapeutic effectiveness can be evaluated after one month. ¶pH monitoring on and off PPI therapy can provide additional evidence before deciding on antireflux surgery. #A properly blinded acid perfusion test can inform the decision of whether to perform antireflux surgery, yet a positive test should not be considered definitive evidence that surgery should be undertaken. MII–pH, multichannel intraluminal impedance and pH monitoring; rGERD, refractory GERD. Scarpellini, E. et al. (2016) Management of refractory typical GERD symptoms Nat. Rev. Gastroenterol. Hepatol. doi:10.1038/nrgastro.2016.50