Heartburn (technically known as gastroesophageal reflux disease, or GERD) is a relatively commonly malady, with about one in five American adults experiencing symptoms of GERD on a weekly basis. Despite what you may see or hear from the pharmaceutical industry, not everyone needs drug therapy or any single product to manage symptoms. Consumers have options ranging from simple over-the-counter preparations (Tums, Maalox and Mylanta for quick relief and Tagamet and Zantac and others for prevention and relief of symptoms) to the proton pump inhibitors (Prilosec, Nexium and others). Although there is a rather confusing array of therapies available, you can identify what is right for you pretty easily.
Heartburn is the result of stomach contents backing up into the esophagus and causing irritation. There is a “valve” called the lower esophageal sphincter that is supposed to keep stomach contents from backing up into the esophagus. This “valve” doesn’t work correctly in people with GERD. In its more severe forms, GERD can cause erosion of the esophagus, with stomach acids literally burning a hole. Constant exposure to stomach contents may be the cause of Barrett’s esophagus, a precancerous condition. And heartburn could be a symptom of something other than reflux. That burning in your chest can also be a sign of heart disease. Heartburn is not to be taken lightly. The correct diagnosis is important. So, if you have symptoms for a prolonged period of time you should seek the advice of your physician or nurse practitioner.
Symptoms of GERD can be reduced or even prevented with a few fairly simple lifestyle changes:
- At night, elevate the head of your bed at least six inches. If possible, put wooden blocks under the legs at the head of the bed or use a solid foam wedge under the head portion of the mattress. Simply using extra pillows may not help.
- Avoid foods that promote acid reflux, especially coffee, chocolate, fatty foods, spicy foods, carbonated beverages, peppermint, spearmint, citrus fruits, tomatoes, whole milk and onions.
- Eat smaller, more frequent meals.
- Do not lie down after eating.
- Do not eat for three to four hours before going to bed.
- If you smoke, quit.
- Avoid drinking alcohol.
- Lose weight if you are obese. Obesity can make it harder for the lower esophageal sphincter to stay closed.
- Avoid wearing tight-fitting garments. These increase pressure on the abdomen, opening the sphincter when it should be shut.
If you are still having symptoms, here’s how to proceed:
If you have symptoms only rarely:
Watch what you are eating. There is likely to be something in your diet causing you to have the symptoms. Try to figure out what it is. Over-the-counter antacids are your best bet for drug therapy. They work quickly and are inexpensive, especially if you buy the store-brand products. These products work by reacting with stomach acids and neutralizing them by a chemical reaction. The liquid forms work quickly but aren’t very convenient. The tablets are convenient but can take a bit of time to work. The number of products available is too long to list but many contain either an aluminum or magnesium hydroxide alone or in combination. These aluminum and magnesium products are your best bet.
The aluminum and magnesium hydroxides actually react chemically with stomach acids to form salts. The best option is a "maximum strength" store-brand product containing both aluminum and a magnesium hydroxide. Most of us produce a fairly consistent amount of acid, so the amount of antacid need to relieve symptoms is usually fairly predictable. The maximum strength products have twice as much neutralizing power and are a bit more convenient and less expensive to use.
If you have more frequent symptoms:
Again, there may be something in your routine diet causing you problems. The histamine-2 receptor-blocking drugs are your next best bet. They don’t work as fast as the antacids but are convenient to take. These drugs (ranitidine, cimetidine, famotidine and nizatidine) block the release of stomach acid from specialized cells in the stomach lining. They do this by blocking an activating receptor called a histamine-2 receptor. All of them work equally well. They are available by prescription and over-the-counter. The over-the-counter versions are half the strength of the prescription-only versions.
If you have very frequent symptoms:
Your physician is likely to prescribe one of the members of a group of drugs called proton pump inhibitors. Some of these drugs are now available as generics, including generic omeprazole (trade name Prilosec) and generic pantoprazole (trade name Protonix). Omeprazole is also available over-the-counter.
All of the proton pump inhibitors work equally as well and have the same side effects, so the only real difference is price. Because of the fierce competition between all of the manufacturers of these drugs, they have worked hard to provide insurance companies with exclusive contracts. Many insurance companies have restrictions on what they will cover. So, the best choice for many people will be the one their insurance company covers or includes in their
For the rest us, the best buy is Protonix. Here's an estimate of the costs for a month's supply of the various proton pump inhibitors at the dose recommended for GERD:
- Prilosec — $116
- Omeprazole (generic of Prilosec) — $94
- Protonix — $99
- Aciphex — $120
- Nexium — $120
- Prevacid — $120
Two additional types of drugs (prokinetic drugs and mucosal protector drugs) are sometimes used in addition, but they are not primary therapy. Metoclopramide (a prokinetic drug also available as brand-name Reglan) and sucralfate (a mucosal protectant also available as brand name Carafate) are both available as generic products. Here too there is a substantial difference in price:
And if you still have symptoms, or your symptoms return immediately after you stop taking your proton pump inhibitor, speak with your doctor. A gastroenterologist probably should see you. At this stage, many would suggest an endoscopy (a procedure in which the gastroenterologist takes a look at your esophagus and stomach lining using a device called an endoscope). If you have severe disease, surgery may be an option.
Most adults will experience heartburn on occasion. Although it is very common and is usually self-limited, persistent heartburn should not be taken lightly.
Harold J. DeMonaco, M.S., is senior clinical associate in the Decision Support and Quality Management Unit at the Massachusetts General Hospital and is currently a Visiting Scholar at the MIT Sloan School of Management. He is author of over 20 publications in the pharmacy and medical literature and routinely reviews manuscript submissions for eight medical journals.