- Choosing an Over-the-Counter Heartburn Remedy
- Medications to Treat Chronic Reflux
- GERD Medications: Over the Counter and Prescription
- Types of Medicines Used for Treating GERD
- Long-Term PPI Use
- See the FDA Proton Pump Inhibitor Safety page for details on long-term side-effects of PPI use.
- Treatment for GER & GERD
- How do you control GER and GERD?
- Gastroesophageal Reflux Disease (GERD) Treatment
- Treatment Approaches for GERD at Johns Hopkins
- GERD Treatment: Lifestyle and Dietary Changes
- GERD Treatment: Medication
- TIF and Other Endoscopic Therapy
- What is heartburn?
- What are my OTC treatment options?
- How do I use these drugs safely and effectively?
- More Safety Information
- More Consumer Information
- Regulatory Information
- GERD: Heartburn and more
- Normal swallowing
- What is GERD?
- Therapy: Lifestyle
- Treatment: Medications
- Treatment: Surgery
- Heartburn Treatment
Choosing an Over-the-Counter Heartburn Remedy
Do you have heartburn that just won’t quit? You may have gastroesophageal reflux disease (GERD), a condition in which stomach acid routinely backs up in the esophagus. The most obvious and painful symptom of GERD is killer heartburn.
Because you can grab over-the-counter heartburn remedies quickly at a drugstore without a doctor’s visit or a prescription, these are often the first line of defense against GERD.
But a glance down the pharmacy aisle shows a vast array of choices, including Tums, Rolaids, Zantac, and Pepcid, to name just a few. (The latter two are also available in high-dose prescription versions.) Which product is the right one to help you quash the burning pain in your chest?
Although it’s easy to feel overwhelmed by the options, a better understanding of your heartburn triggers can help you sort through the clutter and choose the right GERD remedy, says Robynne Chutkan, MD, the founder of the Digestive Center for Women in Chevy Chase, Md.
There are three main categories of over-the-counter heartburn treatment, says Dr. Chutkan, who is also an assistant professor of gastroenterology at Georgetown University Medical Center in Washington, D.C. Each has its own advantages and disadvantages.
The best-known class of drugs for curbing heartburn are the antacids—, think Tums, Rolaids, and Mylanta. Antacids, which contain the salt form of minerals such as magnesium and/or compounds such as calcium carbonate, curb heartburn by neutralizing acids in the stomach. Some antacids are also a supplemental source of calcium. “These products tend to offer instant relief,” Dr. Chutkan says. “If you had corned beef and fries or if you overdid it at dinner and are having symptoms of heartburn, antacids are appropriate. Antacids make more sense for discretionary use and rare episodes of heartburn.”
Antacids are very fast-acting, and relieve reflux symptoms (especially heartburn) right away, says Mitchell Cappell, MD, PhD, the chief of gastroenterology at Beaumont Hospital in Royal Oak, Mich. “They are relatively cheap and have been around for 50 years or more, as opposed to other drugs which are newer and more expensive,” he says.
Standard antacids such as Mylanta or Maalox also are relatively safe, Dr. Cappell says, although some people who use them may experience diarrhea and constipation. “There are not many side effects and you can take them long term,” he says. “But you have to take a lot of antacids because they are not as powerful as other heartburn remedies.”
So how long is it safe to take an antacid? Dr. Cappell says he doesn’t worry so much about toxicity in patients taking antacids long term but is “concerned about patients munching them all the time because they may be suffering from more severe reflux and need a more potent therapy.”
Jonathan Schreiber, MD, a gastroenterologist at Mercy Medical Center in Baltimore sums it up like this: “If your heartburn is brief and related to something you ate, an antacid is fine. It will work quickly and there is little downside, but the negative is that an hour later it’s gone from your system. If you have a recurring problem, an antacid is not the answer.”
Although they do suppress acid and will make you feel better faster, antacids do not heal the lining of the esophagus. The acid churned out by the stomach can erode the lining of the esophagus over time, which can cause Barrett’s esophagus, a precancerous condition that can lead to esophageal cancer.
Histamine 2 blockers
Another class of heartburn drug that you can buy over the counter is a histamine 2 (H2) blocker. These remedies reduce the amount of acid the stomach produces by blocking histamine, an organic compound that tells your stomach to churn out acid. There are prescription and nonprescription H2 blockers; the choices you can find over the counter include Tagamet-HB, Pepcid-AC, Axid AR, and Zantac 75.
“These drugs have been around since the 1970s and appear to be relatively safe,” Dr. Cappell says. They can be used for up to two weeks for short-term relief of heartburn. Side effects may include headache, dizziness, diarrhea, constipation, nausea, and vomiting.
“They are stronger than antacids and their effects are more long lasting,” says Dr. Schreiber. “They are also preventive in that they block acid production in the first place.”
What does that mean for your heartburn? If you take an H2 blocker, it works for eight to 12 hours. “Some people take these medications twice daily and they can be helpful for mild reflux or heartburn,” he says. They help heal the esophageal lining, but not as well as another more potent class of heartburn helpers called proton pump inhibitors (PPI).
Proton pump inhibitors (PPIs)
Available in the United States since 1989, PPIs block an acid-producing enzyme in the lining of the stomach. These drugs also help heal the lining of the esophagus, and do so more effectively than H2 blockers. Prilosec OTC is the only PPI available over the counter; the rest of the drugs in this class require a prescription.
Unlike antacids, PPIs take time to work, Dr. Chutkan says. Some people may not feel better until 24 hours or more after taking them, and that’s a lot to ask of someone who feels like their chest is on fire. Side effects may include diarrhea or stomach pain. “PPIs as a group are very effective and safe, but they don’t work very quickly,” Dr. Schreiber says. “Someone who has heartburn now is probably better off with an H2 blocker or even using an antacid.”
Just how effective are PPIs? The best objective measure of the effectiveness of a heartburn remedy is its ability to reverse erosive esophagitis, a condition in which the lining of the esophagus is visibly irritated or injured. Doctors can measure this using an endoscope (a thin, flexible tube with a camera and a light attached), which is passed into the mouth and down the esophagus. Studies have shown that roughly 85% of people with erosive esophagitis are healed when they take a PPI, according to Dr. Schreiber. Far fewer people are healed of this condition with H2 blockers.
When to see a doctor
Treating heartburn involves more than just popping a pill or munching on a fistful of antacids. These medications work in tandem with lifestyle changes such as cutting out caffeine; consuming smaller, more frequent meals; quitting smoking; and avoiding alcohol, a known heartburn trigger. Other tips that may help extinguish heartburn include not eating after 7 p.m. and propping your head up while you sleep. “You can’t expect a pill to work if you are drinking eight cups of coffee and smoking two packs a day,” Dr. Chutkan says.
Caffeine relaxes the lower esophageal sphincter, a circular muscle that creates a valve between the esophagus and the stomach. Think of the muscle as a door. “When the door is shut, no acid comes back up. But when the door opens, the acid backs up from stomach to food pipe,” Dr. Cappell says. “Caffeine, smoking, and alcohol all tend to make reflux more severe, and they may act by opening this door.”
“If you have classic acid reflux or heartburn such as a pain in chest with frequent burping or nausea, it’s OK to try over-the-counter remedies—especially if it occurs after a large, fatty meal or late at night,” Dr. Chutkan says. Steer clear of the over-the-counter aisle and head straight to your doctor if you have any of these red flags: pain or difficulty swallowing, vomiting, unexplained weight loss, or persistent abdominal pain, she says.
Also call your doctor if your symptoms change in character: If you used to have heartburn, but now food feels like it is stuck in your chest, for example.
“If you have very occasional reflux symptoms——and who doesn’t?——it may be reasonable to take over-the-counter medication. But if you are getting it regularly, if it’s severe, or if the medication that you took before stops working, definitely see a doctor, and preferably a gastroenterologist,” Dr. Cappell says. “The symptoms may be due to another condition, to severe reflux that requires more powerful medicines, or to complications of reflux that require further medical evaluation and treatment.”
Medications to Treat Chronic Reflux
Reflux is a very common condition, but can indicate having Gastroesophageal Reflux Disease (GERD) if it’s chronic. While medication is usually the treatment, you may need to get surgical intervention. For more information, call Mainline Gastroenterology Associates at (610) 644-6755.
GERD Medications: Over the Counter and Prescription
Therapy though medicines may be the most appropriate next step for the treatment of GERD, if diet and lifestyle changes alone do not resolve symptoms. For many patients, treatment with medicines will reduce heartburn and reflux symptoms. Patients with more severe symptoms may only experience partial symptom control through medicines.
Acid suppression is the main function of GERD medical therapy. Three types of medicines are commonly used to treat GERD: antacids, h2-receptors (H2RAs) and proton pump inhibitors (PPIs). Some drugs are available as over the counter (OTC) medications and others are available by prescription only. PPIs are the most commonly used drug to treat GERD symptoms and to heal esophagitis.
Types of Medicines Used for Treating GERD
- Antacids: This type of medication directly neutralizes gastric acid and provides rapid but temporary relief. Antacids are usually consumed in frequent doses as needed, and most are available over the counter.
- H2RAs: H2RAs reduce the amount of acid produced in the stomach by inhibiting the release of histamine, the principal stimulus for acid secretion in the stomach. Clinical trials evaluating histamine for the treatment of GERD showed only modest benefit over a placebo. Also, several studies have revealed drug tolerance to H2RAs as early as two weeks after beginning therapy. This means that patients experience a reduced reaction to a given dosage relatively quickly after starting to use it.
- PPIs: PPIs are the most effective medical therapy to treat GERD . PPIs work by blocking the mechanism that produces stomach acid. This lowers the acidity of the digestive fluids involved in reflux, and thus reduces reflux symptoms. PPIs are available in both prescription and over-the-counter strengths.
While effective at reducing the acidity of digestive fluids in the upper GI tract, PPIs do not address anatomic deficiencies which often are the root cause of abnormal reflux.
Long-Term PPI Use
PPIs are generally approved by the FDA for eight weeks of use for the healing of esophagitis, and they are safe and effective for most patients. However, studies evaluating PPI use over an extended period of time demonstrate several potential long-term concerns including:
- Vitamin B12 deficiency
- Increased pneumonia risk
- Increased risk of osteoporosis fractures
- Reduced gall bladder motility
- PPI interaction with Plavix
- Increased risk of stomach polyps
- Increased risk of bacterial gastroenteritis
- Magnesium deficiency
- Increased risk of small intestine bacterial infection
- Chronic kidney disease
See the FDA Proton Pump Inhibitor Safety page for details on long-term side-effects of PPI use.
Medication can help control symptoms such as heartburn by reducing the acidity of reflux, but it does not change the amount or quantity of reflux. As a result, it can leave other symptoms such as difficulty swallowing, frequent regurgitation, or chronic respiratory problems unresolved.
If the medication regimen is stopped, reflux-related symptoms typically recur. This can lead to dependence on these medicines. Over time, the medication can lose its effectiveness, requiring higher doses or more powerful medicines.
Having reflux from time to time is normal; having it interrupt your life is not. If you suffer symptoms of reflux twice or more per week, you may have GERD. Take the GERD-HRQL survey if you suspect a problem.
For more information on the TIF procedure, view this site: www.GERDHelp.com.
Heartburn is a feeling of burning pain in your lower chest, behind the breastbone. It comes from acid backing up from your stomach to your throat. You may have seen ads for heartburn drugs, such as Nexium, Prilosec or Prevacid. These drugs are called PPIs (proton pump inhibitors). They keep the stomach from making too much acid. They have been shown to heal irritation of the tube between the throat and the stomach (the esophagus).
In most cases, you don’t need a PPI for heartburn. You can get relief from a less powerful drug. And when you do need a PPI, you should take the lowest dose for as short a time as possible. Here’s why:
You may not need a PPI?
More than half of the people who take PPIs probably do not need them. Simple heartburn can be treated with antacids or other drugs, plus diet and lifestyle changes.
You may only have heartburn every now and then—such as after a big, spicy meal. This may be uncomfortable, but it is not serious. You can usually get relief from an antacid, like Rolaids or Tums, or an H2 blocker, such as Pepcid AC or Zantac.
PPIs have risks.
If you need a PPI, taking a low dose for less than a year is probably safe. PPIs are expensive and have been linked to higher risk of some
problems. Talk with your doctor before taking them for longer than two weeks. Be sure you have a good reason to take the PPI, and take it
for the shortest time possible.
Some risks of taking a PPI for a year or longer include:
- Higher risk of certain fractures.
- Higher risk of kidney disease, or kidney disease that gets worse.
- A higher risk of heart attack.
- In people age 75 and older, a higher risk of dementia.
- Trouble absorbing calcium and vitamin B12.
- Low levels of magnesium in your blood.
- An infection in the intestines called Clostridium difficile.
PPIs can change the way other drugs work.
PPIs interact with some common prescription drugs. For example, some PPIs can reduce the blood-thinning effect of the drug Plavix (generic clopidogrel), according to the US Food and Drug Administration. This can increase the risk of heart attack and even death. If you take Plavix, talk to your doctor about whether you should take a PPI.
PPIs cost more.
Why spend more money on a PPI unless antacids or H2 blockers don’t work? Both the prescription and over-the-counter versions of PPIs are usually more expensive than antacids and H2 blockers. If you are worried about cost, talk to your doctor. He or she can help you find
the least expensive medicine that will work for you.
When should you consider a PPI?
Talk to your doctor if you have symptoms such as trouble swallowing, weight loss, or chest pain. Call the doctor if you don’t get better in about two weeks. The doctor will look for signs of problems such as GERD (gastroesophageal reflux disease).
If you have GERD, you probably need a PPI. Talk to your doctor if:
- You have heartburn at least twice a week for several weeks.
- Food or acid often come back up into your throat.
- You take antacid or H2 blockers, and you make changes like the ones described on this page, but your heartburn does not go away.
If your doctor thinks you need a PPI:
- Ask to start with a low dose of generic prescription lansoprazole or omeprazole. You can also get these medicines over the counter.
- If the heartburn gets better after a few weeks, talk to your doctor about gradually lowering your dose.
This report is for you to use when talking with your healthcare provider. It is not a substitute for medical advice and treatment. Use of this report is at your own risk.
© 2017 Consumer Reports. Developed in cooperation with the American Gastroenterological Association.
Treatment for GER & GERD
How do you control GER and GERD?
You may be able to control gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD) by
- not eating or drinking items that may cause GER, such as greasy or spicy foods and alcoholic drinks
- not overeating
- not eating 2 to 3 hours before bedtime
- losing weight if you’re overweight or obese
- quitting smoking and avoiding secondhand smoke
- taking over-the-counter medicines, such as Maalox, or Rolaids
How do doctors treat GERD?
Depending on the severity of your symptoms, your doctor may recommend lifestyle changes, medicines, surgery, or a combination.
Making lifestyle changes can reduce your GER and GERD symptoms. You should
- lose weight, if needed.
- wear loose-fitting clothing around your abdomen. Tight clothing can squeeze your stomach area and push acid up into your esophagus.
- stay upright for 3 hours after meals. Avoid reclining and slouching when sitting.
- sleep on a slight angle. Raise the head of your bed 6 to 8 inches by safely putting blocks under the bedposts. Just using extra pillows will not help.
- quit smoking and avoid secondhand smoke.
Over-the-counter and prescription medicines
You can buy many GERD medicines without a prescription. However, if you have symptoms that will not go away, you should see your doctor.
All GERD medicines work in different ways. You may need a combination of GERD medicines to control your symptoms.
Antacids. Doctors often first recommend antacids to relieve heartburn and other mild GER and GERD symptoms. Antacids include over-the-counter medicines such as
Antacids can have side effects, including diarrhea and constipation.
H2 blockers. H2 blockers decrease acid production. They provide short-term or on-demand relief for many people with GER and GERD symptoms. They can also help heal the esophagus, although not as well as other medicines. You can buy H2 blockers over-the-counter or your doctor can prescribe one. Types of H2 blockers include
- cimetidine (Tagamet HB)
- famotidine (Pepcid AC)
- nizatidine (Axid AR)
- ranitidine (Zantac 75)
If you get heartburn after eating, your doctor may recommend that you take an antacid and an H2 blocker. The antacid neutralizes stomach acid, and the H2 blocker stops your stomach from creating acid. By the time the antacid stops working, the H2 blocker has stopped the acid.
Proton pump inhibitors (PPIs). PPIs lower the amount of acid your stomach makes. PPIs are better at treating GERD symptoms than H2 blockers.2 They can heal the esophageal lining in most people with GERD. Doctors often prescribe PPIs for long-term GERD treatment.
However, studies show that people who take PPIs for a long time or in high doses are more likely to have hip, wrist, and spinal fractures. You need to take these medicines on an empty stomach so that your stomach acid can make them work.
Several types of PPIs are available by a doctor’s prescription, including
Talk with your doctor about taking lower-strength omeprazole or lansoprazole, sold over the counter.
Prokinetics. Prokinetics help your stomach empty faster. Prescription prokinetics include
- bethanechol (Urecholine)
- metoclopramide (Reglan)
Both of these medicines have side effects, including
- fatigue, or feeling tired
- delayed or abnormal physical movement
Prokinetics can cause problems if you mix them with other medicines, so tell your doctor about all the medicines you’re taking.
Antibiotics. Antibiotics, including erythromycin, can help your stomach empty faster. Erythromycin has fewer side effects than prokinetics; however, it can cause diarrhea.
Your doctor may recommend surgery if your GERD symptoms don’t improve with lifestyle changes or medicines. You’re more likely to develop complications from surgery than from medicines.
Fundoplication is the most common surgery for GERD. In most cases, it leads to long-term reflux control.
A surgeon performs fundoplication using a laparoscope, a thin tube with a tiny video camera. During the operation, a surgeon sews the top of your stomach around your esophagus to add pressure to the lower end of your esophagus and reduce reflux. The surgeon performs the operation at a hospital. You receive general anesthesia and can leave the hospital in 1 to 3 days. Most people return to their usual daily activities in 2 to 3 weeks.
Endoscopic techniques, such as endoscopic sewing and radiofrequency, help control GERD in a small number of people. Endoscopic sewing uses small stitches to tighten your sphincter muscle. Radiofrequency creates heat lesions, or sores, that help tighten your sphincter muscle. A surgeon performs both operations using an endoscope at a hospital or an outpatient center, and you receive general anesthesia.
The results for endoscopic techniques may not be as good as those for fundoplication. Doctors don’t use endoscopic techniques often.
Gastroesophageal Reflux Disease (GERD) Treatment
Treatment Approaches for GERD at Johns Hopkins
There are four approaches for GERD treatment, including medication and surgery. Often, patients respond well to a combination of lifestyle changes and a medication regimen.
Some patients do not find satisfactory relief from those methods and require surgical intervention. Other patients may choose surgery as an alternative to a lifetime of taking medication.
Treatment for GERD includes:
- Lifestyle and dietary changes
- Endoscopic therapy
GERD Treatment: Lifestyle and Dietary Changes
Dietary and lifestyle changes are the first step in treating GERD. Certain foods make the reflux worse. Suggestions to help alleviate symptoms include:
- Lose weight if you are overweight — of all of the lifestyle changes you can make, this one is the most effective.
- Avoid foods that increase the level of acid in your stomach, including caffeinated beverages.
- Avoid foods that decrease the pressure in the lower esophagus, such as fatty foods, alcohol and peppermint.
- Avoid foods that affect peristalsis (the muscle movements in your digestive tract), such as coffee, alcohol and acidic liquids.
- Avoid foods that slow gastric emptying, including fatty foods.
- Avoid large meals.
- Quit smoking.
- Do not lie down immediately after a meal.
- Elevate the level of your head when you lie down.
GERD Treatment: Medication
If lifestyle and dietary changes do not work, your doctor may prescribe certain medications. There are two categories of medicines for reflux. One decreases the level of acid in your stomach, and one increases the level of motility (movement) in the upper gastrointestinal tract.
Over-the-counter antacids are best for intermittent and relatively infrequent symptoms of reflux. When taken frequently, antacids may worsen the problem. They leave the stomach quickly, and your stomach actually increases acid production as a result.
Histamine 2 (H2) blockers are drugs that help lower acid secretion. H2 blockers heal esophageal erosions in about 50 percent of patients.
Proton pump inhibitors
Proton pump inhibitors (PPIs) are drugs that block the three major pathways for acid production. PPIs suppress acid production much more effectively than H2 blockers. PPIs heal erosive esophagitis in many patients, even those with severe esophageal damage.
Prokinetic agents are drugs that enhance the activity of the smooth muscle of your gastrointestinal tract. These drugs are somewhat less effective than PPIs. Your doctor may prescribe them in combination with an acid-suppressing drug.
TIF and Other Endoscopic Therapy
Transoral incisionless fundoplication (TIF) is an option to address GERD. TIF can mean a shorter treatment time, less pain and faster recovery compared to laparoscopic surgery. The procedure involves using a special TIF device to create a passageway for a flexible, tube-like imaging instrument called an endoscope. The procedure allows the physician to use preloaded tweezers and fasteners to repair or recreate the valve that serves as a natural barrier to reflux.
Currently, there are clinical trials testing the efficacy of endoscopic therapy for GERD. One form of therapy uses an endoscopic sewing machine to place sutures in the stomach and increase the anti-reflux barrier.
What is heartburn?
Heartburn occurs when stomach contents flow back up into the esophagus—the muscular tube that carries food and liquids from the mouth to the stomach. Also called acid indigestion, heartburn is an uncomfortable, burning feeling in the mid-chest, behind the breastbone, or in the upper part of the abdomen—the area between the chest and the hips. This feeling occurs because the stomach’s digestive juices contain acid. Sometimes people with this problem can taste food or acidic fluid in the back of the mouth.1
What are my OTC treatment options?
There are three classes of OTC medications for the treatment of heartburn.
- E.g. Mylanta, Rolaids, Tums
- Antacids help to treat mild heartburn (indigestion). They work by changing the stomach acid that causes heartburn. 2 ,3
Proton pump inhibitors (PPIs)
- E.g. Prevacid 24h (lansoprazole), Nexium 24h (esomeprazole), Prilosec (omeprazole magnesium), Zegerid (omeprazole and sodium bicarbonate) 4
- OTC Proton pump inhibitors (PPIs) are used to treat frequent heartburn and work by reducing the amount of acid in the stomach4. In contrast, prescription PPIs are used to treat conditions like gastoesophageal reflux disease (GERD), stomach and small intestine ulcers, and inflammation of the esophagus.
- OTC PPIs are only intended for a 14 day course of treatment and can be used up to 3 times per year.
- E.g. Tagamet HB (cimetidine), Pepcid Complete or Pepcid AC (famotidine), Axid AR (nizatidine), Zantac (ranitidine)4
- H2 blockers work by reducing the amount of acid in the stomach5
How do I use these drugs safely and effectively?
- Read the label.
- Do not misuse, abuse, or take these medications for longer than stipulated on the label.
- If your heartburn symptoms persist even after taking these drugs, then talk to a health care professional.
More Safety Information
- Warning: Aspirin-Containing Antacid Medicines Can Cause Bleeding
Proton Pump Inhibitors (PPIs)
- Proton Pump Inhibitors (PPI): Class Labeling Change
- Proton Pump Inhibitors (PPIs): Drug Safety Communication: Clostridium Difficile-Associated Diarrhea (CDAD) Can be Associated With Stomach Acid Drugs
- FDA Drug Safety Communication: Possible increased risk of fracture of the hip, wrist, and spine with the use of proton pump inhibitors
- If you experience a serious side effect, you or your doctor may send a report to the Food and Drug Administration’s (FDA) MedWatch Adverse Event Reporting program online or by phone (1-800-332-1088).
More Consumer Information
- Medline Plus Information on Antacids
- Q&A on Zegerid OTC
- Prilosec OTC (omeprazole) Information
- Q&A on Prilosec OTC
- Medline Plus Information on PPIs
- Medline Plus Information on H2-Blockers
- Rulemaking History for OTC Antacid Drug Products
- Code of Federal Regulations on Antacid Products for OTC Human Use
1Definition of GER
GERD: Heartburn and more
Published: March, 2008
Doctors call it gastroesophageal reflux disease, or GERD. Millions of men call it heartburn, and many others have coughing, wheezing, or hoarseness without realizing that GERD is to blame. By any name, GERD is common, bothersome, and sometimes serious. It is also expensive, draining the American economy of more than $9 billion a year. But once you know you have GERD, you can control it and prevent complications.
A complex set of 29 muscles in your mouth and tongue get the process started. They close off your windpipe (trachea) to protect your lungs, and then move food into your esophagus, or food pipe. The esophagus is a narrow 10- to 13-inch-long tube leading from your throat to your stomach. But food doesn’t just slide down the esophagus. Instead, muscles that encircle the food pipe contract in an orderly, wave-like fashion to propel food into the stomach. That’s why an adventurous (and athletic) guy can perform the old parlor stunt of drinking while standing on his head (as they say on TV — don’t attempt this at home).
Swallowing is normally a one-way affair. To prevent food from returning to the esophagus, the ring-like muscles of the lower esophagus pinch the tube closed. Doctors call these muscles the lower esophageal sphincter, or LES (see figure).
GERD: Acid on the rise
In GERD, stomach acid backs up into the esophagus, injuring sensitive tissues.
What is GERD?
Every time you swallow, the LES relaxes so food can enter your stomach. When your stomach is full, a tiny amount of food can sneak back into the esophagus when you swallow — that’s normal. But in people with GERD, substantial amounts of stomach acid and digestive juices get into the esophagus. The stomach has a tough lining that resists acid, but the food pipe doesn’t. Its sensitive tissues are injured by acid, and, if the acid makes it all the way to the mouth, other structures can be damaged.
Poor function of the LES is responsible for most cases of GERD. A variety of substances can make the LES relax when it shouldn’t, and others can irritate the esophagus, exacerbating the problem. Other conditions can simply put too much pressure on the LES. Some of the chief culprits in GERD are shown below.
Common causes of GERD symptoms
Garlic and onions
Coffee, cola, and other carbonated beverages
Fried and fatty foods
Peppermint and spearmint
Alpha blockers (used for the prostate)
Nitrates (used for angina)
Calcium-channel blockers (used for angina and high blood pressure)
Tricyclics (used for depression)
Theophylline (used for asthma)
Bisphosphonates (used for osteoporosis)
Anti-inflammatories (used for arthritis, pain, and fever)
Tight clothing around the waist
Hiatus hernia (part of the stomach bulges through the diaphragm muscle into the lower chest)
Heartburn and “acid indigestion” are the most common complaints. A burning pain is typical, and when it’s accompanied by burping or bloating, it points to GERD as the cause. But GERD can sometimes cause belly pain that mimics an ulcer. And if acid in the food pipe triggers esophageal spasms, it can cause a heavy or constricting pain that may feel like a heart attack.
If the acid makes it all the way to the throat and mouth, it can cause other problems. And since these problems can occur in the absence of heartburn, they are often misdiagnosed. Here are some of the stealthy signs of GERD:
Mouth and throat symptoms
A sour or bitter taste in the mouth
Regurgitation of food or fluids
Hoarseness or laryngitis, especially in the morning
Sore throat or the need to clear the throat
Feeling that there is a “lump in the throat.”
Persistent coughing without apparent cause, especially after meals
About 19 million Americans have GERD. Most have heartburn and many experience throat or lung symptoms. But a few go on to develop complications. The most common is esophagitis, inflammation of the food pipe. It produces consistent burning pain that can make swallowing and eating difficult. Left untreated, the inflammation can cause ulcers of the tube’s lining, bleeding, or both. Repeated cycles of esophagitis and healing can lead to a scarring and narrowing of the tube (a stricture).
Severe esophagitis only strikes about 2% of people with GERD. An even smaller number develop Barrett’s esophagus, a condition in which severe inflammation and acid conspire to produce premalignant changes in the cells that line the esophagus. Some 2% to 5% of people with Barrett’s esophagus go on to develop cancer. To prevent that, people with severe esophagitis should take medications to suppress acid indefinitely. In addition, patients with Barrett’s esophagus require regular endoscopies to detect any progression toward cancer.
Most people with GERD don’t need any tests at all. If your symptoms are typical and mild, you may even be able to treat yourself. Similarly, if doctors suspect you have uncomplicated GERD, they may recommend a trial of therapy as the next step; if you respond promptly, you probably won’t be asked to have additional tests.
GERD can be puzzling, however, so if the diagnosis is uncertain, tests may be in order. The old standby is the barium swallow, or upper GI series. You’ll be asked to swallow a paste-like solution of barium while a technician takes x-rays to look for ulcers, strictures, a hiatus (also called hiatal) hernia, abnormal contractions of the esophagus, or reflux of barium from the stomach into the food pipe.
Esophageal monitoring is a better way to diagnose GERD. One type, pH monitoring, measures the level of acid in the lower esophagus over a 24-hour period, while manometry measures the pressure in the esophagus during swallowing.
Endoscopy is the best way to detect the complications of GERD, including inflammation, ulcers, strictures, and abnormal or malignant cells. After giving you sedatives and numbing your throat, your doctor will pass a fiber-optic tube through your mouth into your esophagus and stomach. Endoscopy allows the physician to inspect and photograph your tissues and to perform biopsies on any suspicious areas.
Endoscopy is an important test, but it’s not risk-free, so it shouldn’t be done unless necessary. Here are some warning symptoms that may call for endoscopy:
Longstanding or severe GERD
GERD that does not respond to therapy
GERD that begins after age 50
GERD that is accompanied by loss of appetite or weight, vomiting, bleeding or anemia, difficulty swallowing, or the sensation of food sticking in the esophagus.
You can control many symptoms of GERD with simple lifestyle modifications. Here are some tips:
Don’t smoke. It’s the first rule of preventive medicine, and it’s as important for GERD as for heart and lung disease.
Avoid foods that trigger GERD (see “Common causes of GERD symptoms”).
If you are taking certain painkillers, antibiotics, or other medications that can irritate the esophagus or contribute to GERD, ask your doctor about alternatives, but don’t stop treatment on your own.
Avoid large meals and try to be up and moving around for at least 30 minutes after eating. (It’s a good time to help with the dishes.) Don’t lie down for two hours after you eat, even if it means giving up that bedtime snack.
Use gravity to keep the acid down in your stomach at night. Propping up your head with an extra pillow won’t do it. Instead, place four- to six-inch blocks under the legs at the head of your bed. A simpler (and very effective) approach is to sleep on a large, wedge-shaped pillow. Your bedding store may not carry one, but many maternity shops will, since GERD is so common during pregnancy. And because GERD is also so common in general, you won’t be the only man looking for a pillow in a maternity shop.
Chew gum, which will stimulate acid-neutralizing saliva.
Avoid tight belts and waistbands.
If you doubt that GERD is a big problem in the U.S., just check out your local drug store. You’ll find a vast array of over-the-counter (OTC) products to treat it, plus numerous prescription medications behind the pharmacist’s counter. Here is a look at the five types of medication that can help:
Proton-pump inhibitors (PPIs). PPIs are the most effective medications for GERD. That’s because they are the best at shutting down the stomach’s acid production. They act rapidly, but even after you feel better, it may take four to eight weeks to heal an inflamed food pipe. Because GERD tends to recur, patients usually need prolonged therapy, and those with severe esophagitis or Barrett’s esophagus may need high-dose, lifelong treatment. Fortunately, side effects are uncommon, with diarrhea, rash, or headache in fewer than 3% of people taking the medications. Long-term use, particularly at high doses, can increase the risk of osteoporosis (“thin bones”) and fractures. One PPI, omeprazole, is available OTC and by prescription. The others — lansoprazole (Prevacid), rabeprazole (AcipHex), pantoprazole (Protonix), and esomeprazole (Nexium) — are prescription medications.
H2-receptor blockers. These popular drugs were the first to reduce the production of stomach acid. They are widely available OTC in low doses and by prescription in full doses. H2 blockers can provide temporary relief for mild GERD, but are less effective than PPIs. Examples include cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), and nizatidine (Axid).
Antacids. Antacids do not reduce the amount of acid produced by the stomach, but they do neutralize some of it. Many are available over the counter. They reduce acid faster than acid-suppressing medications but provide only temporary relief for mild heartburn. In general, liquid forms work faster than chewable tablets. Antacids that contain magnesium can produce loose stools. Those with calcium can be used as dietary supplements to build stronger bones, but men should not overdo it since they can cause constipation, and high doses of calcium (above 1,200 mg a day) may increase the risk of advanced prostate cancer.
Coating agent. Sucralfate (Carafate) is a prescription drug that protects the esophagus and stomach by forming a protective film on the surface. It is very safe, but long-term benefits are unclear.
Motility agent. Metoclopramide (Reglan), another prescription drug, promotes normal contractions of the esophagus and helps the stomach empty faster. Side effects such as drowsiness, agitation, and tremors limit its usefulness, but it can help some patients with GERD.
Lifestyle modifications and medications — particularly the PPIs — have produced such good results that surgery for GERD is recommended much less often than it used to be. But surgery has improved, too, and it can be very beneficial for patients with severe GERD who don’t respond fully to medical therapy and, perhaps, in young people who are leery of lifelong medication.
The major advance is the introduction of laparoscopic surgery for GERD. While the patient is under general anesthesia, the surgeon makes several small incisions in the abdomen that are used to introduce a fiber-optic tube and tiny surgical instruments. The most popular GERD operation is the Nissen fundoplication, in which the upper portion of the stomach is wrapped around the lower esophagus to prevent reflux. New approaches include using radiofrequency energy to tighten the LES (the Stretta procedure) and tightening the LES with sutures (the Bard system).
How is heartburn treated?
Over-the-counter (OTC) antacids and acid blockers are the most commonly used medicines for treating heartburn. Along with diet and lifestyle changes, they can help relieve the symptoms of occasional heartburn.
If your heartburn is not relieved with OTC antacids or acid blockers, talk to your doctor. You may have gastroesophageal reflux disease (GERD) or another condition that may need different treatment.
Occasional heartburn is common and generally not serious. However, GERD may lead to esophagitis, an inflammation of the lining of the esophagus (food tube). Esophagitis happens when stomach acid repeatedly comes into contact with the lining of the esophagus. If the condition is severe, the person can develop ulcers, bleeding, and blood loss.
GERD may also lead to esophageal stricture, a narrowing of the esophagus that makes it hard to swallow. Barrett’s esophagus and even cancer can occur if reflux and heartburn last a long time.
Your doctor may want to do an endoscopy to check for these or other conditions. An endoscopy is the examination of your digestive tract with a lighted flexible instrument.
How do antacids work to treat heartburn?
Antacids neutralize (reduce) excess stomach acid to relieve heartburn, sour stomach, acid indigestion, and stomach upset. They can also be used to relieve the pain of stomach and duodenal ulcers. Some antacids contain simethicone, which reduces gas. Examples of antacids you can buy without a prescription:
Take antacids as directed by your doctor or by the directions on the package. For ulcers, take the medicine for as long as your doctor tells you. If you use tablets, chew them well before swallowing for faster relief.
Some antacids contain magnesium or sodium bicarbonate, which can act like a laxative. Do not take antacids if you have any symptoms of appendicitis or bowel inflammation. Side effects of antacids may include:
- White or pale bowel movements
- Stomach cramps
Serious side effects can occur with an overdose or overuse of antacids.
How do acid blockers work to treat heartburn?
Products like Pepcid AC® are called histamine H2 blockers, or acid blockers. Acid blockers reduce the production of stomach acid. They relieve heartburn, acid indigestion, and sour stomach. Take these drugs according to the directions on the package, or as your doctor tells you. Acid blockers you can buy without a prescription include:
- Pepcid AC
- Tagamet HB®
- Zantac 75®
- Axid AR®
Take your acid blocker medicine regularly for as long as directed by your doctor, even if you do not have any pain or if your symptoms get better. Side effects of acid blockers include headache, dizziness, and diarrhea.
If you have any of the following possibly serious side effects after taking acid blockers, tell your doctor right away:
- Chest tightness
- Sore throat
- Irregular heartbeat
- Weakness or unusual fatigue
Acid blockers in prescription strength block stomach acid, and treat stomach or duodenal ulcers, erosive esophagitis, and GERD by reducing the production of stomach acid. They may also be used for other conditions as determined by your doctor.
Should I take antacids and acid blockers together to treat heartburn?
Your doctor may want you to take antacids when you start taking acid blockers. Antacids will control your symptoms until the acid blockers start to work. If your doctor prescribes an antacid, take it an hour before (or an hour after) you take an acid blocker.
What are prescription medications for heartburn?
If OTC antacids and acid blockers do not relieve your heartburn, your doctor may give you a prescription for other medicines, such as:
- Prescription-strength acid blockers. In prescription strength (usually higher doses), Zantac, Tagamet, Pepcid, and Axid can generally relieve heartburn and treat GERD.
- Proton pump inhibitors. These are drugs that block acid production more effectively. Proton pump inhibitors include Aciphex®, Nexium®, Prevacid®, Prilosec®, and Protonix®.
- Promotility agents. Drugs such as Reglan® speed up the digestive process. This decreases the amount of stomach acid that splashes back into the esophagus.
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