What are the recommended first-line antacids for treating heartburn and indigestion?

First-Line Antacids for Treating Heartburn and Indigestion

Proton pump inhibitors (PPIs) are the recommended first-line treatment for frequent heartburn and indigestion due to their superior efficacy and sustained acid suppression compared to other antacids. 1

Treatment Algorithm for Heartburn and Indigestion

Step 1: Assess Frequency and Severity

• Occasional/mild heartburn: Antacids (calcium carbonate, magnesium/aluminum salts)
• Frequent heartburn (≥2 episodes/week): Start with PPI therapy

Step 2: First-Line Medication Selection

For Occasional/Mild Symptoms:

• Immediate relief: Calcium carbonate or aluminum/magnesium-based antacids
  • Provide rapid but short-term neutralization of stomach acid
  • Can be used on-demand for breakthrough symptoms 2
  • Alginate-containing antacids are particularly effective for post-prandial symptoms 2

For Frequent Heartburn:

• First-line: Standard-dose PPI (e.g., omeprazole 20mg daily)
  • Take 30-60 minutes before first meal of the day
  • Superior to antacids and H2RAs for sustained acid control 1
  • Consistent with American College of Gastroenterology guidelines 1

Step 3: Adjunctive Therapy for Breakthrough Symptoms

• Add alginate antacids for breakthrough symptoms while on PPI therapy 2
• Add H2-receptor antagonists (H2RAs) for nighttime symptoms 2
  • Note: H2RAs may develop tachyphylaxis (reduced effectiveness) with continued use 2

Evidence-Based Considerations

Antacids (Calcium Carbonate, Magnesium/Aluminum Salts)

• Mechanism: Neutralize gastric acid and inhibit pepsin 3
• Benefits: Rapid onset (within minutes), good for on-demand relief 4
• Limitations: Short duration of action, do not prevent subsequent heartburn episodes 1
• Best use: Occasional heartburn, breakthrough symptoms while on other therapies 3

H2-Receptor Antagonists (H2RAs)

• Examples: Ranitidine, famotidine, cimetidine
• Mechanism: Reduce acid production by blocking histamine receptors
• Benefits: Longer duration than antacids (6-10 hours)
• Limitations: Rapidly develop tolerance with repeated use 1
• Dosing: For ranitidine, 150mg tablet can be taken up to twice daily 5

Proton Pump Inhibitors (PPIs)

• Examples: Omeprazole, lansoprazole, esomeprazole
• Mechanism: Block acid production at the proton pump
• Benefits: Most potent acid suppression, once-daily dosing, sustained effect
• Best use: Frequent heartburn (≥2 episodes/week) 1

Special Considerations

Potassium-Competitive Acid Blockers (P-CABs)

• Not recommended as first-line therapy for typical heartburn and indigestion 2
• Should be reserved for patients who fail twice-daily PPI therapy 2
• Higher cost and fewer long-term safety data compared to PPIs 2

Pediatric Considerations

• Antacids should generally not be first-line therapy for infants and children 2
• For children with GERD, acid suppressants (H2RAs or PPIs) at weight-adjusted doses are preferred 2

Common Pitfalls to Avoid

1. Overuse of antacids: Can lead to electrolyte disturbances with long-term use 3
2. Relying on H2RAs for chronic daily use: Effectiveness diminishes due to tachyphylaxis 2
3. Inadequate PPI timing: PPIs should be taken 30-60 minutes before meals for optimal effect
4. Failure to address lifestyle factors: Weight management and dietary modifications should accompany medication therapy 2

For optimal management of heartburn, clinicians should personalize adjunctive pharmacotherapy to the specific symptom pattern, using alginate antacids for breakthrough symptoms, nighttime H2RAs for nocturnal symptoms, and ensuring PPIs are taken correctly for frequent heartburn 2.