What medications are used to treat heartburn?

Medications for Heartburn

Start with antacids or low-dose H2 receptor antagonists (H2RAs) for immediate relief of episodic heartburn, then escalate to proton pump inhibitors (PPIs) for frequent or persistent symptoms using a step-up approach. 1, 2

Initial Treatment for Episodic Heartburn

Antacids provide rapid but transient symptom relief by neutralizing acid in the esophagus, though they do not significantly affect gastric pH or prevent subsequent episodes 3. Alginate-containing antacids are superior to standard antacids alone, creating a protective "raft" that neutralizes the postprandial acid pocket 2. These are particularly effective for:

• Breakthrough symptoms on PPI therapy 2
• Post-prandial symptoms 2
• Nighttime symptoms 2
• Patients with hiatal hernias 2

Low-dose H2RAs (ranitidine 75 mg, famotidine 5-20 mg) provide more sustained relief than antacids for self-directed treatment of episodic heartburn 4, 5. Ranitidine 75 mg provides relief within 30 minutes that lasts up to 12 hours 4. However, H2RAs rapidly develop tolerance with repeat dosing, limiting their effectiveness for long-term treatment 1, 3.

Treatment for Frequent Heartburn (≥2 days/week)

PPIs are the first-line therapy for frequent heartburn, as they provide sustained inhibition of gastric acid production and are superior to both antacids and H2RAs 3, 6. The recommended approach is:

• Start with standard-dose PPI once daily (omeprazole 20 mg, esomeprazole 20 mg) for 4-8 weeks 2, 7
• Increase to twice-daily dosing if partial response is achieved 2
• Add alginate-containing antacids for breakthrough symptoms 2

A 20 mg PPI dose is optimal for empiric treatment of frequent heartburn and consistent with treatment guidelines 3.

Treatment for Gastroesophageal Reflux Disease (GERD)

For symptomatic GERD without erosive esophagitis:

• Ranitidine 150 mg twice daily is effective for relief of heartburn and GERD symptoms 8
• PPIs remain superior for adequate symptom control, particularly in patients with moderate to severe symptoms 1, 6

For erosive esophagitis:

• Ranitidine 150 mg four times daily heals 84% of erosive esophagitis by 12 weeks 8
• PPIs produce significantly faster and more complete healing compared to H2RAs 6
• Maintenance therapy with ranitidine 150 mg twice daily or PPIs is effective for preventing relapse 8

Step-Up Treatment Algorithm

1. Lifestyle modifications (weight loss, head of bed elevation, avoiding lying down 2-3 hours after meals) plus antacids or alginate-antacids for mild, episodic symptoms 1, 2

2. H2RAs (ranitidine 150 mg twice daily) for patients with unresolved symptoms, though long-term efficacy is limited 1

3. Standard-dose PPI once daily for frequent heartburn or persistent symptoms despite H2RA therapy 1, 2

4. Twice-daily PPI or switch to more potent PPI for inadequate response 2

5. Add adjunctive therapy based on symptom pattern:

   • Alginate-antacids for breakthrough symptoms 2
   • H2RAs for nocturnal symptoms 2
   • Baclofen for regurgitation or belch-predominant symptoms 2

Important Caveats

Avoid cisapride as it has no place in heartburn treatment 1. Cost considerations favor the step-up approach, reserving PPIs for patients with unresolved symptoms on less expensive therapies 1. Undertreatment is common in primary care; adequate symptom control should be prioritized to avoid expensive specialist referrals 1. Treatment duration with esomeprazole 20 mg for 14 days maintains effect for at least one week after cessation without symptomatic rebound 9.