Prescription Medicine and OTC drugs for Constant Heartburn

     It is estimated that upwards of 2 out of 3 adults in the U.S. suffer from occasional heartburn. The symptoms of heartburn generally include a burning and painful sensation beneath the chest along with a feeling of discomfort moving upwards toward the throat and neck. These symptoms occur when acid from the stomach moves upward into the esophagus causing irritation, inflammation, and damage to the tissues.

     Frequent heartburn has been defined as heartburn symptoms occurring 2 or more days per week. Amongst those who have frequent heartburn are up to 25 million U.S. adults who have daily heartburn symptoms. Frequent heartburn should always be discussed with a physician for proper evaluation and to rule out other medical conditions. This article is not intended to replace the need for medical evaluation, or to try to identify all the causes and treatment options for heartburn, but specifically to identify and briefly describe the medication available, both OTC and Rx (prescription), to treat heartburn (also known as GERD or acid reflux). I will also try to provide a listing of internet resources for more helpful information on treating GERD.

A host of antacid products are available over the counter (OTC) to treat ocassional heartburn. These products include popular brands such as:

• Tums
• Rolaids
• Maalox
• Mylanta
• Gaviscon
• Mylanta

These products contain acid-neutralizing ingredients consisting of combinations of calcium, magnesium, and aluminum hydroxide. Some also contain an anti-gas ingredient known as simethicone.

Dosing: Follow dosing guidelines for the particular product as indication on the "directions" portion of the label. These are generally used 3-4 times daily (between meals and at bedtime). That is a lot! This can be inconvenient and often makes them impractical.

Side effects of oral antacids include constipation (usually attributed to aluminum) and diarrhea (usually attributed to magnesium).

Special Notes:

Tums: Tums is primarily calcium carbonate. Therefore it is not only effective at neutralizing acid, but also a useful as a calcium supplement. Can't swallow those big calcium tablets? Try Tums instead!

Gaviscon: In addition to antacid ingredients, Gaviscon contains "alginate" which creates a foam barrier which 'floats' almost like a raft on top of rising stomach acid, protecting the esophagus lining from irritation.

Drug Interactions: Be aware that certain prescription medications should not be taken within several hours of antacids (4 hours before or after is usually safe). These prescriptions include (but are not limited to): Thyroid hormones (e.g. Levoxyl, Synthroid), Quinolones (e.g. Cipro, Avelox), Tetracyclines, Gabapentin (e.g. Neurontin), Digoxin (eg Lanoxin), and biphosphonates (e.g Actonel, Fosamax).

Affordability: Antacids are generally inexpensive and quite affordable for occasional use. Frequent use, however, could get rather expensive and may make other treatment options a better choice.

H2 blockers (the "H" stands for histamine) work, not by neutralizing acid (like antacids), but by slowing down the production and secretion of acid and pepsin within the stomach. They also help reduce the amount of acid released by the stomach in response to normal stimuli such as food or caffeine.  H2 blockers can be used to treat mild to moderate cases of acid indigestion and heartburn.

H2 blockers include Axid, Pepcid, Tagamet and Zantac. They ALL have generics available for them and they ALL are available both by prescription AND OTC. Why are they available BOTH by prescription and otc? They are available in lower dosage forms over the counter (in some cases) which are determined to be safe for self-medication and treatment of mild to moderate symptoms of GERD for short-term only. Manufacturers also include warnings to consumers not to use the product for more than 2 weeks without consulting a physician.

For example:

Tagamet strengths by prescription: 200mg, 300mg, 400mg, and 800mg

Tagamet stengths over the counter (called Tagamet HB): 200mg only

Zantac strengths by prescription: 150mg & 300mg & 150mg/10ml syrup

Zantac strengths over the counter: 75mg and 150mg only

Dosing: Follow dosing recommendations for each individual product as described on the package or on the prescription. Generally these are used twice daily before meals. This is less frequent than antacids, making them somewhat more convenient.

Adverse Reacions & Side Effects: Generally well-tolerated, they may sometimes cause headache, dizziness, constipation and diarrhea.

Affordability: These tend to cost a bit more than antacids. If you use them regularly, and have health insurance, consider requesting a presccription from your doctor as they will be available generically for your lowest copay. Many pharmacies have low-cost generic programs, so even if you don't have insurance, this could save you tons! For more information on pharmacy generic programs like the WalMart $4.00 program, read my other article here.

Special Notes:

Pepcid is available in a variety of convenient dosage forms over the counter including Pepcid AC ezy chews (chewable) and Pepcid Complete (which combines the H2 blocker ingredient with an antacid for faster relief).

Drug Interactions: Less frequent than with antacids, nevertheless there may be interactions with antibiotics of the cephalosporin family (eg Ceftin, Keflex), itraconazole (Sporanox) and ketoconazole (Nizoral). However, cimetidine is a classic inhibitor of several metabolizing enzymes and therefore can contribute to interactions with many prescription drugs. I generally recommend avoiding Tagamet (cimetidine) for this reason (although such interactions are unlikely in the lower dosages available over the counter).

The final major category of medications used to treat constant or frequent heartburn are called Proton Pump Inhibitors, also known as "PPI's". There are now currently 7 Proton Pump Inhibitors on the market, 3 of which (Prilosec, Prevacid & Zegerid) are available in an OTC strength! These are the currently available Proton Pump Inhibitors with links to each manufacturers website:

• Aciphex (rabeprazole)
• Nexium (esomeprazole)
• Prevacid (lansoprazole) - Available in capsules and rapidly dissolving tablets called Solutabs
• Prilosec (omeprazole) - Available by prescrition and OTC as Prilosec OTC 20mg
• Protonix (pantoprazole)
• Zegerid (omeprazole; sodium bicarbonate)
• Dexilant (dexlansoprazole, formerly called Kapidex)

Prilosec, Prevacid, Zegerid and Protonix are avaiable generically at this time.

Proton pump inhibitors work by inhibiting an enzyme system within specific cells of the stomach (known as parietal cells) and prohibits the secretion of acid by blocking the final step in acid production. Proton pump inhibitors are very powerful and effective at reducing gastric acid production and relieving symptoms associated with frequent heartburn or GERD. Studies have shown that within 24 hours up to 50% of patients treated with PPI's experience complete heartburn relief and nearly 80% had just mild heartburn symptoms.

Dosing: Proton Pump inhibitors are typically dosed just once daily with or without food, except for Prevacid which should be administered 30 minutes prior to a meal. They should not be crushed or chewed. The latest addition to this category, Kapidex, is formulated with a special DDR (dual delayed release) mechanism to allow for better 24 hours coverage of symptoms.

Interactions: Patients on warfarin (Coumadin) should be monitored for changes in blood thinning effects. Also, interactions are possible with some forms of ampicillin, itraconazole, ketoconazole, and iron supplements. Fluvoxamine, and anti-depressant, can greatly increase the blood levels of several Proton Pump Inhibitors.

Side Effects: Side effects occurring in patients more than 1% of the time include: abdominal pain, chest pain, rash and itching, diarrhea, and nausea/vomiting. These are typically mild and rarely cause treatment interuptions.

Here are some good sites for more information about frequent hearburn:

Mayo Clinic Article on the treatment of heartburn

Treatment Tips for Frequent Heartburn Sufferers

American Gastroenterological Association on Heartburn

Frequent hearburn affects millions of Americans.  Frequent heartburn should always be assessed by a physician and should not be routinely self treated or left untreated.  This article has just addressed some of the most common treatment options available with OTC and prescription medication.  I hope that the resources and information have been helpful. 

For those looking to save money on prescription treatments for heartburn, or for any other condition, check out my article on how to save thousands on prescription medications!