is step by step. Dietary and lifestyle modifications are the first steps. Twice-daily H2RAs at standard doses for a minimum duration of two weeks can be considered in patients with GERD who fail to respond to lifestyle and dietary modifications. If symptoms of GERD persist, once-daily Proton Pump Inhibitors [PPIs] can be recommended. Patients with an unsatisfactory response to once-daily PPIs dosing can be considered to have refractory GERD. Twice-daily PPI therapy can be recommended in patients who fail to respond to once-daily PPI therapy. The add-on treatment with H2RAs, baclofen, or visceral pain modulators can be considered in selective subjects with GERD who fail to respond to twice daily PPI. Anti-reflux surgery may be taken into account in selected patients. This review focuses on the initial and maintenance therapy of GERD and also reviews different management of recurrent and refractory GERD