Heartburn: What You Need to Know

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Heartburn is a burning sensation in the chest or a bitter taste in the mouth. It occurs when stomach acid backs up (or "refluxes") into the esophagus (the tube that carries food from the mouth to the stomach). Heartburn usually is more severe after a large, high-fat meal. It may become worse when you lie down.

Heartburn generally occurs because of a poorly functioning lower esophageal sphincter (LES). The LES is a muscle resembling a one-way valve that lies between the esophagus and the stomach. It opens when you swallow to allow food and beverages in, and then it closes when they pass through. If the LES does not close properly, or if it "relaxes," it allows acid to flow back into the esophagus. This acid can cause severe irritation and damage to the lining of the esophagus.

Occasional heartburn (or episodic heartburn) occurs less often than 2 days a week. Frequent heartburn occurs 2 or more days a week and can become severe enough to damage the esophagus. If left untreated, severe heartburn can lead to serious problems. If frequent heartburn persists, you should contact your physician.

What Factors Contribute to Heartburn?

Diet, lifestyle factors, certain medications, and medical problems may contribute to the poor functioning of the LES.

• Foods can relax the LES, increase acid in the stomach, or directly irritate the esophagus. Such foods include those high in fat, spicy foods, chocolate, peppermint, citrus fruits, and tomato products. Beverages include carbonated drinks, caffeinated drinks, tea, citrus and tomato juices, and alcohol.
• Eating too much results in the production of more acid and a higher chance of irritation to the esophagus. Reducing the size of meals and avoiding meals at least 3 hours before bedtime may help prevent and/or lessen symptoms.
• Smoking both stimulates the production of acid and interferes with saliva, which protects the esophagus from damage
• Some medications used for anxiety, high blood pressure, and angina decrease the function of the LES. Aspirin, certain antibiotics (for example, tetracycline), and medication to treat osteoporosis can cause direct irritation.
• Pregnancy can result in heartburn, due to both hormone activity and pressure placed by the baby. Pregnant women with persistent heartburn should contact their physicians. Obesity and the presence of a hiatal hernia also can contribute.

What Treatments Are Available?

Lifestyle changes should be undertaken first and foremost (see Table). They may not result in total benefit, however, so drug therapy may be required. The main treatments for heartburn initially are over-the-counter drugs.

Antacids and Alginic Acid

Antacids have long been used to treat mild (episodic) heartburn. They work quickly when they reach the stomach by neutralizing acid. They work on acid that already is present. The effect provided, however, lasts a maximum of 2 to 3 hours. These products may need to be taken several times during the day. Antacids include Tums, Maalox, Mylanta, and Rolaids.

If taken before a meal, antacids may offer relief lasting up to 1 hour. If taken after a meal, the effect may last for up to 3 hours. Antacids can cause side effects. Magnesium-based antacids can cause diarrhea, and those with aluminum can cause constipation. Antacids also may decrease the effects of certain medications if taken at the same time. They should be separated from other medications by at least 2 hours.

Gaviscon contains "alginate" (alginic acid plus sodium bicarbonate). It forms a thick foam that covers the stomach contents and helps protect the esophagus from irritation. Gaviscon tablets are to be chewed and taken with water.

Acid Blockers

Unlike antacids, acid blockers (also known as "H² blockers") decrease the amount of acid made by the stomach. They provide relatively quick relief from heartburn and usually work within 1 hour.

Acid blockers are taken to prevent or relive symptoms. They are best taken before a meal. The effect lasts up to 12 hours. Therefore, they can be dosed up to twice daily. These medications include Tagamet HB, Pepcid AC, Pepcid Max, Axid AR, and Zantac 75. They are available at one-half the strength of the standard prescription dose. Recently, some of these products became available over the counter in prescription strength.

Side effects rarely occur but may include headache, nausea, and diarrhea. Drug interactions are minimal. Cimetidine, however, may interact with drugs such as warfarin (a medication used as a blood thinner), phenytoin (used to treat seizures), and theophylline (used to treat asthma).

Antacid/Acid Blocker Combinations

Pepcid Complete is a combination of an antacid and an acid blocker. This combination offers quick relief by neutralizing stomach acid and reducing acid production, and the effect lasts for up to 12 hours.

Proton Pump Inhibitors

Prilosec OTC is a nonprescription medication designed for people with frequent heartburn. It was available only by prescription until 2003. Prilosec OTC also prevents acid production in the stomach. It belongs to a class of drugs known as "proton pump inhibitors." Billions of "pumps" make acid in the stomach. Prilosec OTC starts shutting down these pumps from the first day of treatment.

Prilosec OTC is the same medication that is available by prescription. It works longer than other heartburn drugs (up to 24 hours). It is taken only once a day, a half-hour to an hour before the morning meal. Prilosec OTC is taken as a 14-day course of treatment for frequent heartburn.

The side effects of this medication generally are mild. They may include headache and diarrhea. Persons taking diazepam (an anxiety medicine), digoxin (a heart medicine), warfarin, or some antifungal medicines should consult with their doctor before taking Prilosec OTC.

Although it may take up to 4 days for Prilosec OTC to provide full effect, it begins as early as the first day. Treatment involves taking 1 pill daily for 14 days. This treatment may be repeated every 4 months, or as directed by a physician.

Summary

If you suffer from heartburn, it is best to start with lifestyle changes. If necessary, over-the-counter medications can help relieve the symptoms, but you should keep in mind possible drug interactions and side effects. Finally, a physician should be consulted if symptoms are not completely eliminated even with the use of medication.

For more information, visit www.healingwell.com, www.helpheartburn.com, or www.prilosecotc.com.

Dr. Pelegrin is the pharmacy manager of a Publix Pharmacy in Miami, Fla.