Heartburn and Acid Reflux: Antacids, H2 Blockers, and PPIs

The three categories

OTC heartburn treatment falls into three groups based on how they work and how fast they work.

Antacids

Calcium carbonate (Tums), magnesium hydroxide (milk of magnesia), aluminum hydroxide, and combinations (Maalox, Mylanta, Rolaids). Neutralize stomach acid directly. Work within minutes. Last 1 to 2 hours. Useful for occasional, predictable heartburn.

H2 blockers

Famotidine (Pepcid), cimetidine (Tagamet). Reduce acid production for 6 to 12 hours. Take about an hour to start working. Reasonable for predictable nighttime heartburn or before a known trigger meal.

Proton pump inhibitors (PPIs)

Omeprazole (Prilosec OTC), esomeprazole (Nexium 24HR), lansoprazole (Prevacid 24HR). Most powerful acid reducers. Take 2 to 4 days to reach full effect. OTC labeling indicates short courses (14 days, repeated up to every 4 months) for frequent heartburn.

Matching the product to your situation

• Heartburn 1 to 2 times per week, predictable triggers: antacid as needed.
• Heartburn 2 to 3 times per week, often at night: H2 blocker at bedtime or before triggers.
• Heartburn most days for more than 2 weeks: PPI for a 14 day course, then reassess.
• Heartburn that does not improve with a PPI: see a clinician.
• Severe symptoms, difficulty swallowing, vomiting blood, black stools: see a clinician promptly.

The long term PPI problem

PPIs are designed for short term use at OTC strength. Many patients end up on daily PPIs for years, well beyond the labeled OTC course. The long term risks include:

• Reduced absorption of vitamin B12, magnesium, calcium, and iron.
• Increased risk of bone fractures, particularly in older adults.
• Increased risk of certain GI infections including C. difficile.
• Possible increased risk of kidney injury.
• Rebound acid hypersecretion when stopped abruptly, which makes coming off them harder.

For patients with severe acid reflux or specific medical conditions, long term PPIs may be appropriate under clinical supervision. For patients self treating, the goal should be the lowest effective dose for the shortest reasonable duration.

Lifestyle factors that matter

Several non medication factors significantly affect heartburn frequency.

• Eat smaller meals.
• Avoid eating within 3 hours of lying down.
• Avoid common triggers including spicy foods, citrus, tomato based foods, chocolate, peppermint, coffee, alcohol, and carbonated drinks.
• Elevate the head of the bed if nighttime symptoms are bothersome.
• Lose weight if overweight.
• Avoid tight clothing around the waist.
• Stop smoking.

Drug interactions to know

• PPIs reduce absorption of certain medications including some HIV drugs, ketoconazole, and iron supplements.
• Omeprazole interacts with clopidogrel (Plavix). Pantoprazole or famotidine are usually preferred for patients on Plavix.
• H2 blockers, particularly cimetidine, affect metabolism of several medications including warfarin and certain seizure medications.
• Calcium and magnesium containing antacids can reduce absorption of several antibiotics, thyroid medications, and bisphosphonates. Separate by 4 hours.

When to see a clinician

• Heartburn that has not improved after 2 weeks of OTC treatment.
• Difficulty or pain with swallowing.
• Unexplained weight loss.
• Black, tarry stools or vomiting blood.
• Chest pain, particularly with exertion (rule out cardiac).
• Persistent nausea or vomiting.

When to talk to a pharmacist

• You take Plavix and are considering a PPI.
• You have been on a daily PPI for more than 2 months.
• You are pregnant.
• You take multiple medications and want to confirm timing.
• You are unsure whether your symptoms are reflux or something else.

This article is for general information only and is not a substitute for personalized medical advice. Before starting or changing any medication, including over the counter products and supplements, talk with your pharmacist or physician about your specific situation.