Although gastroesophageal reflux disease is among the most common disorders seen by gastroenterologists, the wide variation in both its symptoms and severity has led to a lack of consensus about the most appropriate practical approach to treatment of patients with acute symptoms. This review considers the efficacy of the most widely used pharmacologic agents in the acute treatment of gastroesophageal reflux disease: H2-receptor antagonists, proton-pump inhibitors, and prokinetic agents. Possible treatment strategies in which they may be used are discussed and it is proposed that individualized treatment strategies should be developed based on symptoms and severity of disease. Emphasis is placed on the fact that, given the wide variety of effective agents available, the use of the same agent in every patient, regardless of their symptoms, is a most inappropriate approach. A stepwise approach to therapy utilizing a number of drug classes is discussed and the rationale for and appropriate use of both a 'step-up' and 'step-down' approach is considered.