Heartburn treatment options that won’t come back to bite you

Recent studies have made people who use proton pump inhibitors (PPIs) feel a little uneasy, but when used appropriately or swapped out entirely for dietary/lifestyle changes, heartburn sufferers may safely find relief.

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As a gastroenterologist, I hear from patients every day who suffer from varying degrees of chronic heartburn. As if the physical discomfort of their condition isn’t enough to deal with, many heartburn patients are now coming to me with concerns about the antacid medications they have been prescribed to ease their symptoms and reduce their pain.

One such class of antacid medications, known as proton pump inhibitors (PPIs), are sold by prescription and over-the-counter under brand names like Nexium, Prilosec, and Prevacid. PPIs are popular and effective medications. However, in recent months there have been numerous reports and studies suggesting that PPIs could pose serious side effects and may even put your health at risk. One particular study, published in the British Medical Journal, linked the use of PPIs to early death. This study also suggested that risk increased with long-term use of these medications.

Many heartburn sufferers who are regular users of PPIs are now understandably worried. As a result, many have come to me asking the same question: Are PPIs safe to take?

I begin by telling patients that we need to be very cautious about how we interpret the findings from this recent BMJ study, which was an observational study over nearly six years that examined the health records in the U.S. Veterans Affairs system of new prescription users and non-users of acid suppression therapy. One of the limitations of this study was that the patient population was largely homogenous: mostly older white, male U.S. veterans. In addition, this study did not include information on the cause of death, so we don’t know how and why patients in this study died. Since observational studies inherently increase the possibility that there may be other associations, we need to be cautious about extrapolating these results to the general population.

That being said, this study and others like it—which have found associations between PPIs and kidney disease, dementia, mineral deficiencies, infection and stroke—do indicate that we should be examining and refining our prescribing practices. I think it’s fair to say that while PPIs offer a clear benefit, they are often over and sometimes inappropriately prescribed.

Chronic heartburn should not be ignored

While some patients with heartburn might see these studies and be tempted to “tough it out,” that’s not a safe option for those with chronic heartburn, also known as gastroesophageal reflux disease (GERD). If left untreated, chronic GERD can potentially have significant long-term consequences. When stomach acid repeatedly washes up into and bathes the esophagus, it can lead to inflammation (esophagitis) that can be associated with bleeding, ulcerations, and even stricturing (or narrowing) of the esophagus.

In a small percentage of patients, long-term exposure to excess acid can also increase the risk for the development of a pre-malignant condition known as Barrett’s esophagus. GERD has also been linked to several extra-esophageal manifestations such as pneumonia, asthma, chronic cough and laryngitis.

My bottom line for patients who are concerned about PPIs is that these medications have a favorable track record spanning nearly three decades, during which they have been shown to be very effective in treating most acid-related disorders, including chronic heartburn. When appropriately prescribed, the benefits of PPIs are likely to outweigh their potential risks.

Discuss your condition with your primary care doctor

Your primary care doctor may ultimately refer you to a gastroenterologist. Regardless of who you see, if your health care provider does advise the use of a PPI, I recommend keeping these points in mind:

  1. When appropriately prescribed, PPIs should be taken 30 minutes to one hour prior to breakfast (and dinner only if prescribed for twice daily use).
  2. You should take the lowest dose possible to alleviate your symptoms. This may mean only taking one dose per day.
  3. PPIs must be taken daily since their benefit is seen in preventing future heartburn symptoms and episodes. PPIs should not be used on an as-needed basis or for the acute and immediate relief of heartburn symptoms. For acute relief of GERD symptoms, over-the-counter medications such as TUMS (calcium carbonate) or H2 receptor blockers such as Zantac (ranitidine) or Pepcid (famotidine) may be more effective.
  4. If you’re taking a PPI for a condition other than heartburn, such as esophagitis or a gastric ulcer, you may require a short duration (usually eight weeks) of treatment and may not need long-term or chronic therapy.

How to treat less-severe heartburn

While PPIs may be useful in treating chronic heartburn, I usually advise a different course of action for my patients with episodic or intermittent symptoms.

I recommend patients first take a look at their diet to determine if there are any foods or lifestyle practices that trigger their heartburn. Acidic foods such as oranges and grapefruits, for example, are a common culprit. And while you might not expect it, other fruits such as grapes and apples also fall into this category. Spicy and tomato-based foods may also exacerbate GERD. I recommend that patients take a trial-and-error approach by avoiding one of the many trigger foods to see if that makes a difference in their symptoms. Although it can be tough to give up pizza or spicy Indian food—especially if they are personal favorites—sometimes avoidance turns out to be the best course of treatment.

In some patients, a weakened or altered anatomy is to blame for their persistent GERD symptoms. When the muscles of the lower esophageal sphincter (LES) either open too often or fail to close tightly, stomach acid can seep into the esophagus to cause heartburn. Some foods and habits are known to cause the LES to relax, including alcohol, tobacco, chocolate, peppermint and caffeine. Avoiding these may decrease the chances that the LES will relax and thus decrease the chances for developing symptomatic heartburn.

In other patients, a hiatal hernia may exacerbate GERD symptoms. A hiatal hernia is an anatomic condition in which the stomach pushes up and through a small opening in the diaphragm and into the chest. When this opening becomes weak and enlarged, food and stomach acid will reflux into the esophagus and cause heartburn. While small and moderately-sized hernias are usually treated medically and through lifestyle modifications, very large hiatal hernias often require surgical repair.

Fortunately, I’ve found that many patients will experience a noticeable improvement by making relatively small dietary or lifestyle changes.

PPI alternatives

For patients with intermittent symptoms or for those who may be hesitant to use PPIs, I often suggest an H2 receptor blocker such as Zantac or Pepcid.

While studies have demonstrated that these medications may not be as efficacious as PPIs in the treatment of GERD, esophagitis and peptic ulcer disease, H2 receptor antagonists may be helpful for the acute relief of episodic symptoms. These medications specifically target a substance called histamine, and blocking this will reduce the production of acid within the stomach. These medications are also safe and have not received the attention that PPIs have about potentially adverse effects.

Some patients with mild symptoms may have success using chewable antacids such as TUMs. Chewable antacids usually combine aluminum, magnesium or calcium with hydroxide or bicarbonate ions that can quickly neutralize stomach acid. These medications may be used alone or in combination with PPIs and H2 receptor antagonists.

Whether you find relief for your chronic heartburn by changing your diet/lifestyle or by taking certain medications, the important thing to remember is to not to let your condition go untreated. Talk to your doctor to determine the safest and most effective course of treatment for you.

Eric R. Wollins, M.D., is chief of gastroenterology for Mid-Atlantic Permanente Medical Group. He sees patients at the Kaiser Permanente Falls Church Medical Center.