What over-the-counter (OTC) medications are safe for heartburn during pregnancy?

OTC Medicine for Heartburn in Pregnancy

Start with calcium-containing antacids as first-line OTC medication for heartburn in pregnancy, followed by ranitidine (H2-receptor antagonist) if symptoms persist.

Treatment Algorithm

Step 1: Lifestyle and Dietary Modifications (First-Line)

• Reduce intake of spicy, fatty, acidic, and fried foods 1
• Eat small, frequent meals rather than large portions 1, 2
• Identify and avoid specific food triggers that worsen symptoms 1, 2
• These modifications should be attempted first, but don't delay pharmacologic treatment if symptoms are moderate to severe 2

Step 2: Calcium-Containing Antacids (First-Line OTC Medication)

• Calcium-containing antacids are the preferred first-line OTC medication for heartburn in pregnancy 3
• These work by neutralizing stomach acid and provide rapid symptom relief 3
• Safe throughout all trimesters of pregnancy 3

Step 3: Ranitidine/H2-Receptor Antagonists (Second-Line OTC)

• If antacids fail to control symptoms, ranitidine (H2-receptor antagonist) is the preferred next step 4, 3
• Ranitidine has documented efficacy and safety even in the first trimester 4
• According to FDA labeling, ranitidine is Pregnancy Category B with no evidence of harm to the fetus in animal studies at doses 160 times the human dose 5
• Ranitidine is secreted in breast milk, so caution is advised during breastfeeding 5

Step 4: Sucralfate (Alternative Second-Line)

• Sucralfate 1g orally three times daily can be used if H2-receptor antagonists are insufficient 3
• One trial showed sucralfate provided complete heartburn relief more effectively than dietary/lifestyle advice alone (RR 2.41,95% CI 1.42 to 4.07) 6
• Sucralfate is not systemically absorbed, making it particularly safe during pregnancy 3

Step 5: Proton Pump Inhibitors (Reserved for Severe Cases)

• PPIs should be reserved for women with intractable symptoms or complicated reflux disease 4, 3
• Lansoprazole may be the preferred PPI due to its safety profile in animal studies and case reports in human pregnancies 4
• PPIs are typically prescription-only and not available OTC 3

Important Clinical Considerations

Safety Profile

• Approximately two-thirds of pregnant women develop heartburn, primarily due to decreased lower esophageal sphincter pressure from progesterone 4
• Serious reflux complications during pregnancy are rare, so aggressive diagnostic testing is rarely needed 4
• Magnesium and aluminum hydroxide combinations (like Maalox) have been studied and show complete heartburn relief more often than placebo (RR 1.85,95% CI 1.36 to 2.50) 6

Common Pitfalls to Avoid

• Don't delay pharmacologic treatment when lifestyle modifications fail - early treatment prevents symptom progression and improves quality of life 2
• Avoid sodium bicarbonate-containing antacids as they can cause fluid retention and metabolic alkalosis in pregnancy 3
• Be cautious with magnesium-containing antacids near term as they may interfere with labor 3

When to Escalate Care

• If symptoms persist despite H2-receptor antagonists and antacids, consider prescription-strength PPIs in consultation with an obstetrician 3
• Severe, intractable symptoms may require endoscopy, though this is rarely needed 4