What is the treatment for heartburn in non-pregnant individuals?

Treatment for Heartburn in Non-Pregnant Adults

Proton pump inhibitors (PPIs) are the most effective first-line treatment for heartburn in non-pregnant adults, superior to H2-receptor antagonists and antacids for both symptom relief and healing of esophagitis. 1

Initial Management Algorithm

Step 1: Lifestyle Modifications (Implement Immediately)

• Weight loss is the single most effective lifestyle intervention for overweight or obese patients with heartburn, with the strongest evidence for preventing or postponing the need for acid suppression 1
• Elevate the head of the bed 6-8 inches for patients experiencing nighttime heartburn or regurgitation that disturbs sleep 1
• Avoid lying down for 2-3 hours after meals to reduce esophageal acid exposure 1
• Identify and avoid individual trigger foods (coffee, chocolate, alcohol, spicy foods, citrus, tomatoes) rather than applying blanket dietary restrictions 1
• Limit fat intake to less than 45g per day 1
• Stop smoking and limit alcohol consumption 1

Step 2: Pharmacological Treatment

First-Line: Proton Pump Inhibitors

• Start with standard once-daily PPI dosing (e.g., omeprazole 20mg, taken 30 minutes before breakfast) 1, 2
• PPIs are superior to H2-receptor antagonists for healing esophagitis and achieving symptomatic relief 1
• Most patients with uncomplicated heartburn do not require endoscopy before starting empiric PPI therapy 1

Alternative First-Line: H2-Receptor Antagonists

• Ranitidine 150mg twice daily is effective for heartburn relief, particularly for patients with mild-to-moderate symptoms 3, 4
• H2-receptor antagonists are less effective than PPIs but more effective than placebo 1
• Symptomatic relief commonly occurs within 24 hours of starting ranitidine 150mg twice daily 3
• Important caveat: H2-receptor antagonists can cause tachyphylaxis within 6 weeks, limiting long-term effectiveness 5

Antacids: Adjunctive Only

• Use antacids as needed for breakthrough pain relief, not as primary therapy 3
• Chronic antacid therapy is generally not recommended due to limited efficacy and potential risks 5

Treatment Escalation for Persistent Symptoms

Step 3: Optimize PPI Therapy (If Symptoms Persist After 4 Weeks)

• Increase to twice-daily PPI dosing (one dose before breakfast, one before dinner) for patients with persistent symptoms despite standard once-daily dosing 1
• Ensure proper timing: PPIs should be taken 30 minutes before meals for optimal effectiveness 5
• Allow 2-3 months for full therapeutic response, especially for extraesophageal symptoms like chronic cough 1

Step 4: Consider Endoscopy

• Perform endoscopy after failed empiric PPI therapy to assess for esophagitis, Barrett's esophagus, or other pathology 1
• Endoscopy is particularly important if warning signs are present: dysphagia, weight loss, gastrointestinal bleeding, or anemia 1

Step 5: Refractory GERD Management

For patients failing twice-daily PPI therapy after 3 months:

• Implement a strict antireflux diet (≤45g fat/24 hours, eliminate coffee, tea, soda, chocolate, mints, citrus, alcohol) 5, 1
• Consider adding prokinetic therapy to PPI treatment, though benefits may not outweigh adverse effects (drowsiness, restlessness, extrapyramidal reactions) 5
• Avoid metoclopramide as monotherapy or adjunctive therapy due to unfavorable risk-benefit profile, including risk of tardive dyskinesia 1
• Address comorbid conditions that worsen GERD, such as sleep apnea 1
• Consider antireflux surgery for patients with objectively documented GERD failing maximal medical therapy for at least 3 months 5, 1

Special Considerations

Extraesophageal Symptoms (Chronic Cough, Laryngitis, Asthma)

• More intensive therapy is required: twice-daily PPI dosing for 8-12 weeks minimum 5, 1
• Response rates are lower for extraesophageal symptoms compared to typical heartburn 1
• Allow 1-3 months to assess response before escalating treatment 5
• If cough persists after 3 months of maximal medical therapy, consider 24-hour esophageal pH monitoring 5
• Antireflux surgery improves or cures cough in 85-86% of properly selected patients who have failed intensive medical therapy 5

Erosive Esophagitis

• Ranitidine 150mg four times daily is effective for healing erosive esophagitis, with 84% healing rate at 12 weeks 3
• Omeprazole is indicated for short-term treatment (4-8 weeks) of erosive esophagitis in patients 2 years and older 2
• Acid suppression with PPIs is essential for documented esophagitis, as lifestyle modifications alone are insufficient 1

Maintenance Therapy

• After initial symptom control, titrate to the lowest effective PPI dose 1
• Periodically reassess the need for continued PPI therapy to minimize potential long-term risks (impaired cognition, bacterial gastroenteritis, community-acquired pneumonia, hip fractures, vitamin B12 deficiency, hypomagnesemia, chronic kidney disease) 1
• For erosive esophagitis, ranitidine 150mg twice daily is effective for maintenance of healing 3

Common Pitfalls to Avoid

• Don't broadly recommend all lifestyle modifications to every patient without individualizing based on their specific triggers, as this leads to poor compliance 1
• Don't add nocturnal H2-receptor antagonist to twice-daily PPI as standard practice, as there is no evidence of improved efficacy 1
• Don't use doses higher than standard PPI dosing without first optimizing timing and ensuring twice-daily dosing 1
• Don't delay treatment in patients with chronic symptoms, as adequate acid suppression is essential to effective management and quality of life 6
• Don't double the dose of ranitidine (from 150mg to 300mg twice daily) for poorly responsive patients, as this is not efficacious 7