What are the recommended medications for treating heartburn?

Recommended Medications for Heartburn

Start with lifestyle modifications and antacids for occasional symptoms, then use a step-up approach with H2-receptor antagonists (H2RAs) for persistent symptoms, reserving proton pump inhibitors (PPIs) for patients who fail H2RA therapy or have more severe disease. 1

Initial Management Approach

Lifestyle Modifications and Antacids

• Begin with lifestyle advice including dietary modifications, weight reduction if overweight, and elevation of the head of the bed, combined with antacids for as-needed symptom relief. 1
• Antacids provide rapid but transient relief by neutralizing acid in the esophagus, though they do not significantly affect gastric pH or prevent subsequent heartburn episodes. 2
• Antacids are effective for individual, spontaneous heartburn episodes when used on an as-needed basis. 3

Step-Up Pharmacological Treatment

First-Line: H2-Receptor Antagonists

• For patients with unresolved symptoms despite lifestyle modifications and antacids, initiate H2RA therapy as first-line pharmacological treatment. 1
• Ranitidine 150 mg twice daily is the recommended starting dose for symptomatic relief of heartburn. 4
• Ranitidine 75 mg taken as needed (up to four times daily) provides prompt relief within 30 minutes that lasts up to 12 hours for intermittent heartburn. 5
• Effervescent ranitidine 150 mg twice daily is more effective than antacids in reducing heartburn frequency and severity, with significant improvement seen after just 1 day of treatment. 6

Important caveat: H2RAs rapidly develop tolerance with repeat dosing and have limited efficacy in long-term treatment, which is a significant limitation of this drug class. 1, 2

Second-Line: Proton Pump Inhibitors

• Reserve PPIs for patients who remain symptomatic after adequate trial of H2RA therapy (typically 6-8 weeks) or those with documented erosive esophagitis. 1
• Omeprazole 20 mg once daily is the standard PPI dose for empiric treatment of heartburn. 7, 2
• PPIs are superior to H2RAs for symptom control: in patients who failed ranitidine therapy, 70% achieved no more than mild heartburn with omeprazole versus only 49% continuing ranitidine. 8
• PPIs provide sustained inhibition of gastric acid production and are superior to both antacids and H2RAs for control of gastric acid and treatment of frequent heartburn. 2

Cost-Effectiveness Considerations

• The enormous cost of PPIs to healthcare systems justifies the step-up approach, starting with less expensive H2RAs before escalating to PPIs. 1
• In clinical practice, marginal cost differences between medications should be weighed against effectiveness, with H2RAs being significantly less expensive than PPIs. 1

Treatment Duration and Monitoring

Short-Term Treatment

• Most patients with heartburn heal within 4 weeks of appropriate therapy; some may require an additional 4 weeks. 7, 4
• For symptomatic GERD, treatment duration of 4 weeks is typically sufficient, with symptomatic relief commonly occurring within 24 hours of starting therapy. 4

Escalation Strategy

• If symptoms persist on once-daily PPI therapy, increase to twice-daily dosing before considering treatment failure. 9
• For patients with erosive esophagitis who do not respond to 8 weeks of standard-dose PPI treatment, an additional 4 weeks may be given. 7
• Rapid relief of symptoms is important because inadequate treatment inevitably leads to higher referral rates for endoscopic examination. 1

Special Populations and Considerations

Severe or Refractory Disease

• For patients with severe erosive esophagitis (Los Angeles grade C/D) who fail twice-daily PPI therapy, potassium-competitive acid blockers (P-CABs) may be considered, though their significantly higher cost limits routine first-line use. 1
• P-CABs should generally not be used as first-line therapy for uninvestigated heartburn or nonerosive reflux disease due to cost and limited long-term safety data. 1

Medications to Avoid

• Cisapride has no place in the treatment of heartburn in primary care. 1
• Metoclopramide is not recommended as monotherapy or adjunctive therapy for GERD symptoms due to insufficient evidence of benefit. 9

Common Pitfalls

Undertreatment

• Undertreatment of gastro-oesophageal reflux disease is repeatedly observed in primary care, with patients experiencing heartburn on average 5.5 days per week and affecting daily activities in 65% of cases. 1
• Doctors must understand the need for adequate symptom control and how reflux symptoms affect overall health, rather than accepting persistent symptoms. 1

Inappropriate Long-Term H2RA Use

• Continuing H2RA therapy when symptoms persist is a common error; patients who remain symptomatic after 6 weeks of H2RA therapy should be switched to PPI therapy rather than continuing ineffective treatment. 8
• Approximately 65% of patients remain symptomatic after 6 weeks of ranitidine 150 mg twice daily and require escalation to PPI therapy. 8