What heartburn medications are safe to use during pregnancy?

Safe Heartburn Medications During Pregnancy

Start with lifestyle modifications and calcium-containing antacids, then escalate to H2-receptor antagonists (ranitidine, famotidine) if needed, reserving proton pump inhibitors only for severe, intractable symptoms. 1

Stepwise Treatment Algorithm

First-Line: Lifestyle and Dietary Modifications

• Reduce intake of spicy, fatty, acidic, and fried foods 2
• Consume small, frequent meals rather than large portions 2
• Identify and avoid specific food triggers, particularly those with strong odors 2
• These modifications alone may be sufficient for mild symptoms and carry zero risk to the fetus 1, 3

Second-Line: Non-Systemic Medications

Calcium-containing antacids are the preferred first-line pharmaceutical option (Recommendation Grade A) 1

• These agents are not systemically absorbed and offer minimal to no risk to the fetus 4, 3
• Can be used as needed for symptom relief throughout pregnancy 1

Sucralfate 1g orally three times daily can be added if antacids alone are insufficient (Recommendation Grade C) 1

• Like antacids, sucralfate is not systemically absorbed and is considered safe 4, 3

Third-Line: H2-Receptor Antagonists

If symptoms persist despite antacids and sucralfate, escalate to H2-receptor antagonists (Recommendation Grade B) 1

• Ranitidine and famotidine are FDA Pregnancy Category B, meaning animal studies show no fetal harm 5, 3
• Ranitidine has been studied in rats and rabbits at doses up to 160 times the human dose with no evidence of impaired fertility or fetal harm 5
• Avoid nizatidine during pregnancy, as it lacks the same safety profile as other H2-blockers 4, 3
• These agents can be used throughout pregnancy when needed 3

Fourth-Line: Proton Pump Inhibitors (PPIs)

Reserve PPIs only for severe, intractable symptoms unresponsive to H2-blockers (Recommendation Grade C) 1

• All PPIs except omeprazole are FDA Category B drugs 3
• Lansoprazole may be the preferred PPI choice based on animal teratogenicity studies 4
• Use the lowest effective dose for the shortest duration necessary 4
• PPIs should be considered only after consultation with a physician about risks versus benefits 1

Critical Safety Considerations

Timing Matters

• Early treatment is essential to prevent progression to hyperemesis gravidarum 2
• Heartburn typically presents in the first trimester and progresses throughout pregnancy, affecting up to 80-90% of pregnant women 1, 3

Medications to Avoid

• Avoid metoclopramide and ondansetron before 10 weeks of gestation due to potential teratogenic risks 2
• Avoid nizatidine among the H2-receptor antagonists 4, 3

Breastfeeding Considerations

• Ranitidine is secreted in human milk; use with caution during lactation 5
• Most H2-receptor antagonists (except nizatidine) are considered safe during breastfeeding 3
• Lifestyle and dietary modifications remain the safest approach for breastfeeding mothers 6

Clinical Pitfalls to Avoid

Do not assume symptomatic response rules out gastric malignancy, though this is rare in pregnancy 5

Monitor for drug interactions if using ranitidine with other medications, particularly warfarin (monitor prothrombin time), midazolam (monitor for excessive sedation), and drugs dependent on gastric pH for absorption 5

Adjust ranitidine dosing in patients with renal impairment, as it is primarily excreted by the kidneys 5