In September 2003, when the U.S. Food and Drug Administration ruled that a prescription would no longer be required to purchase the heartburn medication Prilosec (omeprazole), the agency placed directly into the hands of consumers one of the most effective medications available for heartburn. Introduced as a prescription medication in 1988, Prilosec belongs to a group of heartburn medications known as proton pump inhibitors (PPIs).
"PPIs have had a significant impact on the treatment of chronic heartburn," says Johns Hopkins gastroenterologist Frank Herlong, M.D. "Over-the-counter access to Prilosec will clearly be beneficial for many people," he says. "But Prilosec is not always the best choice for heartburn, and those who use it for heartburn must be careful the medication does not mask symptoms that could indicate a potentially serious complication."
Heartburn: Common but not Trivial
About 45 million Americans suffer from occasional heartburn—a burning sensation behind the breastbone that may extend toward the neck and throat. Other common heartburn symptoms include increased pressure behind the breastbone, a bitter or sour taste in the back of the throat, bloating, gas, and general abdominal discomfort. An additional 15 million Americans experience chronic heartburn, usually due to a condition known as gastroesophageal reflux disease (GERD).
Heartburn and GERD occur when the lower esophageal sphincter, a ring of muscle tissue at the base of the esophagus, opens inappropriately and allows stomach acid and other fluids to flow back (reflux) into the esophagus. Such leakage is more likely after a large meal, after consuming certain foods or beverages, and when lying down. Virtually everyone has some amount of reflux. Whether symptoms develop depends on how often and how long the esophagus is bathed in stomach fluids.
Although GERD is more serious and potentially damaging than simple heartburn, its symptoms are not necessarily more severe. In addition to gastrointestinal discomfort, people with GERD may develop chest pain, cough, and shortness of breath that might be mistakenly attributed to angina, a heart attack, or asthma. Over time, the esophagus may narrow owing to inflammation, and the buildup of scar tissue may lead to hoarseness, difficulty swallowing, or a feeling that food is stuck in the throat.
Persistent GERD may cause a serious complication known as Barrett’s esophagus, a condition that occurs when irritated cells in the lower esophagus are replaced by acid-tolerant cells more characteristic of the stomach. No symptoms are associated with these cellular changes, but they cause the color of the lower esophagus to change from pink to bright red. About 700,000 Americans have Barrett’s esophagus. The condition is a concern largely because it increases the risk of esophageal cancer.
Drug Treatment Options for Heartburn and GERD
The goals of treating heartburn and GERD are to eliminate discomfort, promote healing of the esophageal lining, and prevent recurrent episodes. Many people can prevent heartburn symptoms by avoiding foods and beverages that trigger symptoms; raising the head of the bed; not eating too close to bedtime; not smoking; maintaining a reasonable weight; and wearing loose-fitting clothing.
Those who need additional help can choose from three types of over-the-counter (OTC) heartburn medications.
- Antacids neutralize stomach acid and provide immediate heartburn relief. They include Tums, Maalox, Mylanta, and others.
- Histamine 2—or H2—blockers reduce the production of stomach acid, provide short-term heartburn relief within an hour, promote healing of the esophageal lining, and may provide long-term relief. They include Tagamet (cimetidine), Pepcid (famotidine), Axid (nizatidine), and Zantac (ranitidine ).
- Prilosec and other PPIs suppress nearly all production of stomach acid, promote healing, and provide only long-term relief. The other PPI formulations are Nexium (esomeprazole), Prevacid (lansoprazole), Protonix (pantoprazole), Zegerid (omeprazole/sodium bicabonate) and Aciphex (abeprazole).
Choosing a Drug for Heartburn and GERD
Antacids are best used for mild, occasional symptoms of heartburn. Although they provide quick relief, their effect is short-lived and, because stomach acid is still present, they do not promote healing.
H2 blockers and PPIs reduce acid production by different mechanisms. H2 blockers permit some acid production to continue, take about an hour to work, and their effect can last the entire day. Many people with heartburn and GERD get good immediate results by combining an H2 blocker with an antacid.
PPIs should be used only for long-term relief of heartburn and GERD symptoms. They nearly eliminate stomach acid, but it can take up to 4 days for the full benefit to take effect—although some people get complete relief within 24 hours. No ill effects have been associated with stomach acid suppression.
OTC dosages of H2 blockers and Prilosec are appropriate for moderate, occasional heartburn and GERD symptoms. H2 blockers can be taken as needed but should not be used at their maximum dosage for more than 14 days. Prilosec must be taken for the entire 14-day period and should not be used more than once every four months without a doctor’s supervision.
Higher-dose versions of H2 blockers, Prilosec, and other PPIs are available by prescription. The American Gastrointestinal Association has determined that there is little difference, other than price, between the medications in each group.
When to See Your Doctor for Heartburn and GERD
If heartburn symptoms are severe or persist for more than 14 days, or if you find yourself needing an OTC heartburn medication more than a few times a month, see your doctor. Many people with GERD initially require high-dose therapy with an H2 blocker or PPI, sometimes followed by maintenance therapy at the lowest effective dose. An H2 blocker is often tried first, followed by a PPI for long-term maintenance. Although both types of medications are generally well tolerated, people taking them for heartburn or GERD should be monitored so that the condition of the lower esophagus can be periodically assessed.
Continuing to use OTC products on your own could mask other gastrointestinal problems, including Barrett’s esophagus. The only way for people with persistent GERD to know if they have that condition is through direct examination of the esophagus, a procedure known as endoscopy. The procedure takes about 10 minutes and is usually painless.
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