What is the initial treatment for a patient presenting to urgent care with heartburn?

Initial Treatment for Heartburn in Urgent Care

Start with a proton pump inhibitor (PPI) at standard dose once daily for 4-8 weeks as first-line therapy for patients presenting with heartburn without alarm symptoms. 1, 2

Immediate Management Approach

First-Line Pharmacologic Treatment

• Prescribe omeprazole 20 mg once daily taken before meals as the most effective initial therapy, superior to H2-receptor antagonists and antacids for symptom relief and healing. 2, 3, 4
• PPIs provide significantly faster and more complete symptomatic relief compared to ranitidine or other H2-receptor antagonists. 5, 4
• Antacids may be used concomitantly for breakthrough symptoms while waiting for PPI to take full effect (typically within 24-48 hours). 3, 6

Dosing Instructions for Omeprazole

• Take 20 mg once daily before meals for 4-8 weeks. 3
• For patients unable to swallow capsules: open capsule, mix pellets with one tablespoon of applesauce, and swallow immediately without chewing pellets. 3
• If a dose is missed, take as soon as possible unless the next dose is due; do not double up. 3

Lifestyle Modifications to Prescribe Immediately

• Avoid lying down for 2-3 hours after meals to reduce esophageal acid exposure. 2, 7
• Elevate the head of the bed for patients with nighttime symptoms or regurgitation when recumbent. 2, 7
• Recommend weight loss for overweight or obese patients, as this directly improves GERD symptoms. 2
• Avoid trigger foods on an individualized basis (coffee, chocolate, alcohol, spicy foods, citrus, tomatoes) if these consistently worsen symptoms. 2

When Standard Therapy Fails

Escalation at 4-8 Weeks

• If symptoms persist despite once-daily PPI after 4-8 weeks, increase to twice-daily dosing (omeprazole 20 mg twice daily before meals). 1, 2
• Doubling the dose of H2-receptor antagonists like ranitidine is NOT efficacious—less than 20% of patients achieve complete heartburn resolution with this approach. 8

Red Flags Requiring Endoscopy

• Refer for endoscopy if: 1
  • Alarm symptoms present (dysphagia, odynophagia, weight loss, GI bleeding, anemia)
  • Symptoms do not respond adequately to twice-daily PPI after 4-8 weeks
  • Patient requires long-term PPI therapy without confirmed diagnosis
  • Age >50 years with new-onset symptoms

Common Pitfalls to Avoid

Do NOT Use These as First-Line

• Do NOT use P-CABs (potassium-competitive acid blockers) as initial therapy for uninvestigated heartburn due to higher costs, less availability, and insufficient long-term safety data compared to PPIs. 1, 2
• Do NOT use metoclopramide as monotherapy or adjunctive therapy for GERD due to unfavorable risk-benefit profile. 2, 7
• Do NOT continue or escalate H2-receptor antagonists (like ranitidine) in patients who remain symptomatic after 6 weeks—switch to PPI instead, as 65% of patients remain symptomatic on ranitidine and omeprazole provides superior relief (70% vs 49% achieving mild or no heartburn). 5

Reassessment Timeline

• Assess response at 4-8 weeks after initiating therapy. 1
• If adequate response achieved, taper to the lowest effective dose or consider on-demand therapy. 1
• For patients requiring chronic PPI without confirmed GERD, evaluate appropriateness within 12 months and consider endoscopy with prolonged wireless pH monitoring off PPI to establish need for long-term therapy. 1

Special Considerations

Extraesophageal Symptoms (Chronic Cough, Hoarseness)

• These require more intensive therapy with twice-daily PPI for 8-12 weeks minimum rather than standard once-daily dosing. 2
• Response rates are lower for extraesophageal symptoms compared to typical heartburn. 2
• Allow 1-3 months to assess response before considering treatment failure. 2

Safety Counseling

• Emphasize the safety of PPIs for GERD treatment to address patient concerns about long-term use. 1
• Periodically reassess the need for continued therapy to minimize potential long-term risks. 2