What are the recommended treatments for managing heartburn?

Management of Heartburn

For occasional heartburn (less than 2-3 times weekly), start with as-needed antacids or low-dose H2-receptor antagonists (famotidine 10-20 mg or ranitidine 75 mg); for frequent symptoms (2-3+ times weekly), initiate once-daily proton pump inhibitor therapy (omeprazole 20 mg or lansoprazole 15 mg) taken 30-60 minutes before the first meal of the day. 1, 2

Initial Treatment Algorithm

For Occasional Heartburn (< 2-3 times weekly)

First-line options:

• Antacids provide relief within minutes and are more effective than placebo for individual heartburn episodes 1, 3
• Low-dose H2RAs (famotidine 10-20 mg or ranitidine 75 mg) provide relief within 30-60 minutes, lasting up to 12 hours, and are superior to antacids 1, 4, 3
• All these agents have safety profiles comparable to placebo when used appropriately 1

Escalation:

• If symptoms occur more than 2-3 times weekly or H2RAs provide insufficient relief, advance to short-course PPI therapy (omeprazole 20 mg or lansoprazole 15 mg once daily) 1, 2

For Frequent Heartburn (≥ 2-3 times weekly) or GERD

First-line therapy:

• PPIs are the most effective pharmacological treatment, superior to H2RAs and placebo 5, 2
• Initiate a 4-8 week trial of once-daily PPI taken 30-60 minutes before the first meal to maximize efficacy 2
• Standard doses: omeprazole 20 mg, lansoprazole 15-30 mg, or equivalent 6

Treatment optimization:

• After symptom control (typically 4-8 weeks), taper to the lowest effective dose 2
• Do not taper in patients with erosive esophagitis, Barrett's esophagus, or peptic stricture 2

Lifestyle Modifications

Strongly recommended (Grade B evidence):

• Weight loss for all overweight or obese patients—this has dose-dependent benefits with significant symptom reduction 7, 1, 5
• Elevate the head of the bed for patients with nighttime heartburn or regurgitation when recumbent 7, 1, 5

Individualized recommendations:

• Avoid lying down for 2-3 hours after meals to reduce esophageal acid exposure 1, 5
• Identify and avoid specific food triggers (coffee, alcohol, chocolate, fatty foods, citrus, carbonated drinks, spicy foods) only if these consistently provoke symptoms 7, 1
• Avoid late evening meals 1

Critical caveat: Do not broadly advocate all lifestyle changes for every patient—tailor recommendations based on individual symptom patterns 7

Management of Persistent Symptoms

If symptoms persist on standard once-daily PPI:

• Increase to twice-daily PPI dosing (before breakfast and dinner) 5
• Add alginate-containing antacids for breakthrough symptoms 7, 2
• Consider adding bedtime H2RA for nocturnal symptoms (though tachyphylaxis limits long-term use) 7, 2

If symptoms persist despite optimized PPI therapy (3 months of maximal therapy):

• Perform upper endoscopy with esophageal biopsies to assess for erosive esophagitis, Barrett's esophagus, or alternative diagnoses 7, 5
• Consider esophageal pH monitoring or pH-impedance testing to objectively document acid exposure and symptom correlation 8

Special Considerations

Extraesophageal Symptoms (chronic cough, hoarseness, asthma)

• These symptoms are less likely to respond to PPI therapy 7
• Require more intensive therapy: twice-daily PPI for 8-12 weeks minimum 5
• Investigate non-GERD causes before proceeding to extensive testing if PPI therapy fails 7

Functional Heartburn

• Diagnosed when heartburn persists despite maximal PPI therapy with normal endoscopy, normal esophageal acid exposure, and negative symptom-reflux association 8
• PPIs have no therapeutic value in functional heartburn 8
• Consider neuromodulators (tricyclic antidepressants, SSRIs) as primary therapy 7, 8
• Acupuncture and hypnotherapy may provide benefit 8

Common Pitfalls to Avoid

• Failure to optimize PPI timing: Must be taken 30-60 minutes before meals, not at bedtime or with meals 2
• Assuming GERD is ruled out after failed empiric therapy without objective testing: Many patients require endoscopy or pH monitoring for accurate diagnosis 2
• Using metoclopramide as monotherapy or adjunctive therapy: Unfavorable risk-benefit profile 5
• Continuing long-term PPI without periodic reassessment: Regularly evaluate the need for continued therapy to minimize potential long-term risks 5