Acute Treatment for Severe Heartburn
For severe heartburn, initiate full-dose proton pump inhibitor (PPI) therapy—such as omeprazole 20 mg, lansoprazole 30 mg, or esomeprazole 40 mg once daily taken 30-60 minutes before meals—as first-line treatment for 4-8 weeks. 1
First-Line Therapy
- Standard-dose PPI therapy is the most effective initial treatment for severe heartburn, superior to H2-receptor antagonists (H2RAs) and significantly more effective than placebo 1
- PPIs should be taken 30-60 minutes before meals to ensure the medication is present in the secretory canaliculus when postprandial acid secretion peaks 1
- Typical starting doses include omeprazole 20 mg daily, lansoprazole 30 mg daily, or esomeprazole 40 mg daily 1, 2
Response Assessment and Dose Adjustment
- Assess symptom response at 4-8 weeks after initiating therapy 1
- If heartburn resolves within the first week of PPI therapy, this predicts sustained symptom reduction at 4 weeks (85% of patients who are heartburn-free on days 5-7 remain heartburn-free at week 4) 1
- For partial or inadequate response to standard-dose PPI, increase to twice-daily dosing (e.g., omeprazole 20 mg twice daily or lansoprazole 30 mg twice daily) before meals 1
The evidence strongly supports this step-up approach: while twice-daily PPI dosing is not FDA-approved, expert consensus unanimously recommends it for patients with unsatisfactory response to once-daily therapy 1. Switching to a different PPI at standard dose is equally effective as increasing to twice-daily dosing 3.
Alternative and Adjunctive Options
- H2-receptor antagonists (ranitidine 150 mg twice daily) are less effective than PPIs but can be used if PPIs are contraindicated or unavailable 1, 4
- For immediate symptom relief while awaiting PPI effect, antacids provide rapid onset of action and can be combined with antisecretory therapy 1
- Alginate-containing antacids may be added for breakthrough symptoms while on PPI therapy 1
Newer Agents: Potassium-Competitive Acid Blockers (P-CABs)
- P-CABs (vonoprazan, tegoprazan) provide more potent and prolonged acid suppression than PPIs with longer half-lives (6-9 hours vs 1-2 hours) and acid-stable formulations 1
- P-CABs should generally NOT be used as first-line therapy for uninvestigated heartburn due to higher cost, limited long-term safety data, and lack of superiority over standard PPIs in most patients 1
- P-CABs may be considered in carefully selected patients who fail twice-daily PPI therapy with documented acid-related reflux 1
Common Pitfalls to Avoid
- Do not use cisapride as it has been withdrawn due to cardiac toxicity 1
- Do not use metoclopramide as monotherapy or adjunctive therapy for heartburn—it is not recommended based on fair evidence of ineffectiveness 1
- Avoid empiric PPI therapy beyond 8-12 weeks without objective testing if symptoms persist despite twice-daily dosing 1
- Patients who fail twice-daily PPI therapy should undergo endoscopy to evaluate for erosive esophagitis, Barrett's esophagus, or alternative diagnoses rather than continuing empiric dose escalation 1
Lifestyle Modifications
While lifestyle advice alone is insufficient for severe heartburn, specific modifications benefit certain patients:
- Elevate the head of the bed for patients with nighttime heartburn or regurgitation 1
- Avoid specific trigger foods (alcohol, coffee, spicy foods) if they consistently provoke symptoms 1
- Weight loss is reasonable for overweight/obese patients as an intervention that may reduce the need for long-term acid suppression 1
Treatment Duration and Follow-Up
- After initial symptom control with 4-8 weeks of therapy, consider a trial of therapy withdrawal to assess for symptom recurrence 1
- Most patients (75-79%) experience rapid relapse after stopping therapy, with median time to relapse of 8-9 days 5
- For patients requiring chronic therapy, reassess appropriateness and dosing within 12 months, considering objective testing (endoscopy, pH monitoring) to confirm GERD diagnosis 1