A Word on Heartburn

Dr. Salrin is a community pharmacist and health plan consultant in Portland, Oregon.

Have you ever had that burning feeling in your chest or throat after a large meal? The burning sensation is most likely heartburn, which is the sensation felt from a back-flow from the stomach irritating the esophagus. Any number of things can contribute to heartburn-from obesity and pregnancy, to eating certain foods (citrus, chocolate, fatty and fried foods, spicy or tomato-based foods).^1,2

All of us may have occasional heartburn, but frequent heartburn (2 or more times a week) may be part of a more serious problem, including GERD (gastroesophageal reflux disease).^1-3 GERD is diagnosed by a doctor and is a digestive problem in which the acid in your stomach backs up into the esophagus on a regular basis. This can occur when the valve that separates the stomach and esophagus becomes weak or fails to close properly.^1,2

While the most common symptom of GERD is heartburn, less common symptoms include dry cough, trouble swallowing, sore throat, or a feeling of a lump in the throat. A diagnosis of GERD is often based on a patient's description of symptoms, and your family doctor may want to take a complete history and physical before making a diagnosis.^1-3

The common symptoms of infrequent heartburn can be treated with simple changes in lifestyle, including limiting caffeine intake, avoiding foods that cause symptoms, smoking cessation, and maintaining ideal body weight (Table 1).^1,2 But sometimes lifestyle modifications are not enough. Many over-the-counter (OTC) options are currently available to relieve heartburn (Table 2). These include antacids, H-2 blockers, combination H-2 blocker/ antacid products, and Prilosec OTC (the only proton pump inhibitor [PPI] currently available without a prescription).^2,4 Which one you choose will depend on the severity of your symptoms, your budget, and possibly other medications you are taking.

Antacids provide almost immediate relief of symptoms by neutralizing the acid in your stomach. They are available in many formulations, flavors and textures, in tablet and liquid forms, and can contain a variety of active ingredients, such as aluminum, magnesium, and calcium salts. Antacids, like any other drug, can have side effects or offer additional benefits.^3,4

Magnesium-based products can lead to diarrhea, and aluminum-based agents may cause constipation. There are some products (eg, Gaviscon) that combine both ingredients to balance this effect.^1,4

High-potency calcium carbonate antacids, such as Tums Ultra, also can be a supplemental source of calcium (it is estimated that as many as two thirds of women are not meeting their daily calcium requirements).^2,4,5 There are also foaming agents (Gaviscon also is an example) that work by covering your stomach contents with foam to prevent reflux.^2,4 The main drawback to both antacids and foaming agents is their relatively short duration of action.

H-2 blockers have formulations that are available without a prescrip- tion. These drugs have been in use since the 1960s, are well studied, and considered very safe. Three of the 4 (famotidine, cimetidine, and ranitidine) are even considered safe during pregnancy,^6-8 although you should always consult your physician before taking these or any products while pregnant.

H-2 blockers act by decreasing gastric acid production, have an onset of action in less than 30 minutes, and have a much longer duration of action, compared with antacids. They are, however, more expensive than antacids and may interact with other medications you may be taking.^6-8

Combination H-2 blocker/antacid products also are available and offer both immediate relief of symptoms from the antacid component and sustained acid control from the H-2 blocker. This combination can be beneficial for control of symptoms at night.

PPIs have been used since the late 1980s and have been a standard in the treatment of GERD. PPIs work by inhibiting the final step in gastric acid secretion. For maximum effect, they should be taken prior to the first meal of the day, unless your main problem is symptoms at night. If this is a problem, the best time to take a PPI is prior to the evening meal.^3,9

PPIs are more effective than H-2 blockers and can relieve symptoms and heal the esophageal lining in people with GERD. One of the drawbacks to PPIs is that they have a long onset of action, and it may take a couple of days for maximum effect. Therefore, you may want to consider taking an antacid, H-2 blocker, or combination product until the PPI has taken full effect (no more than 5-7 days).^3,9,10

The PPI "Prilosec OTC" should not be taken for more than 14 days without a physician's recommendation.¹¹ Once a physician has determined the appropriate symptom-relieving regimen with a prescription or OTC PPI, treatment may continue for 4 to 8 weeks or more. Because there are potential issues that can arise with long-term PPI therapy, you should ask your physician if you need to take some time off of the medication.^3,9,10

Although continuous PPI therapy is very effective, many people can still experience episodes of breakthrough heartburn. If this occurs, you can supplement your therapy with an antacid or combination antacid/H-2 blocker product.¹²

When heartburn or other symptoms of GERD are not properly controlled, other more serious complications may occur. It is important to talk with your pharmacist or physician if your current treatment regimen is not relieving your symptoms.

Conclusion

Although heartburn can be bothersome and even scary at times, it is manageable if you make a few simple lifestyle changes. If medication is required for symptom relief, numerous options are available. Keep in mind the cost, safety, and onset of action/relief that may be associated with each choice. Ask your pharmacist which medications may be right for you and your situation.

Table 1

Lifestyle Modifications to Help Prevent Heartburn

Limit caffeine intake Avoid tight clothing

Avoid foods that cause your symptoms Do not lie down for 2 hours after eating

Smoking cessation Bed blocks-raising head of bed 6-8 inches

Maintain ideal body weight Eat smaller meals

Table 2

Examples of Over-the-Counter Medications for the

Treatment of Heartburn

Category Active Ingredient(s) Brand Name(s)

Antacids Aluminum hydroxide and

magnesium Gaviscon

Calcium carbonate Maalox (Regular, Extra-Strength),

Rolaids (Regular, Extra-Strength),

Tums (Regular, Extra-Strength,

Ultra)

Magnesium hydroxide Ex-Lax milk of magnesium

Phillips' Milk of Magnesia

Sodium bicarbonate and citric

acid Alka-Seltzer Heartburn Relief

Bismuth

subsalicylate Bismuth subsalicylate Kaopectate

Pepto-Bismol

Maalox Multi-Action

H-2 Blockers Cimetidine Tagamet HB 200

Famotidine Pepcid AC

Nizatidine Axid AR

Ranitidine Zantac 75

H-2 Blockers

with antacid Famotidine, calcium carbonate,

magnesium hydroxide Tums Dual Action

Pepcid Complete

Proton pump

inhibitor Omeprazole Prilosec OTC