What should be done for acid reflux that does not respond to antacids like Tums (calcium carbonate)?

Management of Acid Reflux When Antacids Don't Work

For acid reflux that does not respond to antacids like Tums (calcium carbonate), patients should be started on a proton pump inhibitor (PPI) such as omeprazole 20mg once daily before a meal for 4-8 weeks as the next step in treatment. 1

Step-wise Approach to GERD Management

First-line Treatment (When Antacids Fail)

• Proton Pump Inhibitors (PPIs):
  • Start with standard once-daily dose before a meal 1, 2
  • Examples: omeprazole 20mg, lansoprazole 30mg, or pantoprazole 40mg
  • Initial treatment duration: 4-8 weeks 1, 2

If Inadequate Response After 4 Weeks

1. Increase to twice-daily PPI dosing 3, 1
2. OR switch to a different PPI (some patients respond better to specific PPIs) 1

Monitoring and Assessment

• Assess symptom response weekly during first month of therapy 1
• If symptoms persist despite 8 weeks of treatment, consider:
  • Increasing to twice daily PPI dosing if not already done 3
  • Reflux monitoring with pH/impedance testing to confirm diagnosis 3

When to Consider Further Evaluation

• For heartburn or regurgitation not responding to twice-daily PPIs:
  • Perform pH/impedance monitoring to diagnose increased acid exposure, non-acid reflux, or functional heartburn 3
• For chest pain, throat or respiratory symptoms not responding to twice-daily PPIs:
  • Perform reflux monitoring with pH/impedance to determine if symptoms are related to acid or non-acid reflux 3

Why PPIs Are Superior to Antacids and H2 Blockers

• PPIs provide more potent and longer-lasting acid suppression than antacids 4
• H2 receptor antagonists are effective for mild GERD (70% symptom improvement) but less effective for more severe forms (40-60% improvement) 5
• Antacids only provide short-term relief - calcium carbonate's effect on esophageal pH lasts about 60 minutes compared to aluminum/magnesium hydroxide's 82 minutes 6

Common Pitfalls to Avoid

• Don't continue ineffective antacid therapy: Persistent symptoms require stepping up to more effective acid suppression
• Don't miss non-acid reflux: Some patients have symptoms from non-acid reflux that won't respond to acid suppression alone 3
• Don't overlook compliance issues: PPIs should be taken 30-60 minutes before meals for maximum effectiveness
• Don't continue indefinite PPI therapy without reassessment: Consider tapering after symptom control is achieved 1

Special Considerations

• For patients with persistent symptoms despite appropriate PPI therapy, consider:
  • Functional heartburn (requires different management approach)
  • Non-acid reflux (may require additional therapies)
  • Other diagnoses (eosinophilic esophagitis, achalasia, etc.)

Remember that the goal of treatment is to improve quality of life by controlling symptoms and preventing complications such as esophagitis, strictures, and Barrett's esophagus, which can impact long-term morbidity and mortality.