Heartburn is a symptom, not a disease. Gastroesophageal reflux disease (GERD) is a disease that is associated with heartburn that has been present for an extended period of time and there is a reduction in the quality of life.

Heartburn is caused by:

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Over-the-counter products

Table 4: Foods and medications that can aggravate or contribute GERD/heartburn

For those individuals who are unsuccessful with lifestyle management, multiple over-the-counter products can be tried for many people who suffer with heartburn. The most common medications include: antacids, histamine-2 receptor blockers (H2RA) and proton pump inhibitors (PPI).

Episodic heartburn is managed with antacids and/or OTC H2RAs. The only over-the-counter PPI is omeprazole (Prevacid may soon become over-the-counter). It is indicated for frequent heartburn.

H2RAs and PPI heal the esophagus and relieve symptoms. Over-the-counter medication is only indicated for short periods of time and many with GERD need long-term management. Over-the-counter management

The following steps can be applied to the patient with signs and symptoms suggestive of heartburn with out any red flags. All individuals with heartburn should implement lifestyle modifications.

The first two questions that need to be asked are: Is the heartburn less than two times a week or equal to or greater than 2 times a week? Is the heartburn mild, moderate or severe?

If it is less than two times a week and mild than you have 4 options:

• Antacids (Tums)
• Alginic acid/antacids (Gaviscon Tablets)
• OTC H2RA (Tagamet)
• OTC H2RA plus an antacid (Pepcid Complete)

If it is less than two times a week and moderate that you have 4 options

• Antacids
• Alginic acid/antacids
• Higher dose OTC H2RA
• OTC H2RA plus an antacid

1. If you have frequent heartburn than you should use an OTC PPI for 14 days and if the symptoms have not resolved in two weeks visit your doctor.
2. If you have mild have symptoms less than twice a week and your symptoms subside after the treatment outlined above than you can repeat the treatment for up to two more weeks if the symptoms return.
3. If you have mild/moderate symptoms and you have not responded to the above treatment you can switch to one of the other options or a trial of a PPI for 2 weeks or visit your doctor.

Bismuth Subsalicylate

Bismuth subsalicylate (Pepto-Bismol) is used in upset stomach and may help with heartburn. It coats the esophagus and provides a barrier to acid, thereby reducing symptoms.

It is not one of the most highly recommended products, but it is used by some. It may turn the tongue or stools black. It contains an aspirin product and should not be used by someone who cannot take aspirin.

It should not be used in those younger than 12. There is a product that is children's Pepto-Bismol, that is actually an antacid, and is safe in those as young as two years old.

It should not be used by children with a fever, as there is a risk of a rare neurological condition called Reye's syndrome.

This product has multiple drug interactions and should not be used by those also taking: blood thinners, aspirin, probenecid, some antibiotics, and methotrexate.

Antacids

Antacids do not prevent heartburn, but may help treat symptoms as they work by neutralizing stomach acid. They do not reduce acid secretion. They have a short duration of action and will work within 20 minutes when taken on an empty stomach but may take longer when taken with food. You can repeat the dose in 1-2 hours.

Most antacids are similar in efficacy, but each product may be associated with separate side effects. For example, calcium-containing products (Tums) are more likely to cause constipation, whereas magnesium-containing products (Mylanta) are more likely to cause diarrhea.

Antacids come in a variety of formulations including pills, liquid, lozenges and powders.

Alginic acid is added to some products (Gaviscon Tablets). It forms a viscous solution that floats on top of the gastric contents and acts as a mechanical barrier to reduce the irritation of acid on the esophageal walls. It may be a little more effective than plain antacids.

Side effects of antacids include:

• Electrolyte imbalance (More common in those with kidney problems)
• Constipation (aluminum and calcium containing products)
• Diarrhea (magnesium containing products)
• Fluid overload (sodium containing products)
• Can affect the absorption of many other medications

Different products may need to be tried to determine which works best for you. If this medication is used more than twice a week different therapy is indicated.

Histamine Receptor Blockers

Histamine receptor blockers (also known as histamine receptor antagonists) (H2RAs) decrease acid secretion in the stomach. Over-the-counter products come in different formulations. They are generally equally effective. Cimetidine (Tagamet) has the most problems as it has a short duration of action and has multiple drug interactions. But it is the cheapest. I do not recommend using cimetidine.

The onset of action is slower than antacids – it takes about 30-45 minutes before effect is noticed. The medicines work up to 10 hours depending which medication is taken.

Unlike antacids they can be used to prevent heartburn and therefore can be taken when you are doing an activity that will bring on heartburn. This may include eating a meal that is highly likely to aggravate heartburn.

They are indicated for those 12 and older. Side effects are not common but may include: dizziness, headache (the most common), diarrhea, constipation and sedation.

The combined use of antacids and H2RAs are better than either product alone in the management of heartburn. Some products (Pepcid Complete) combine these two agents.

Proton pump inhibitors

Currently only omeprazole (Prilosec) is available OTC in this class, but lansoprazole (Prevacid) may be available at some point in the near future. There are many prescriptions proton pump inhibitors (PPIs). These are the most potent acid suppressing medications. Some acid is suppressed within one hour and effects of one drug may last for up to three days.

But, they typically do not work quickly. It may take a number of days before maximal effectiveness is noticed with PPIs.

This is used for those with heartburn more than 2 times a week in those over the age of 18. It should not be used on an as needed basis. Many people use it this way and there will likely be some improvement, but it is not the best way to use the medication.

The medication should be taken in the morning before breakfast. It is taken for 14 days. It may be repeated once every four months.

If symptoms persist beyond 14 days – a follow up with your doctor is indicated.

Side effects include diarrhea and headache. It can interact with some seizure mediations and blood thinners (warfarin).

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