Home Management of Heartburn
For home management of heartburn, start with weight loss if overweight (BMI ≥25), elevate the head of the bed 6-8 inches for nighttime symptoms, avoid lying down for 2-3 hours after meals, and use over-the-counter antacids or low-dose H2-receptor antagonists for occasional symptoms—escalating to once-daily proton pump inhibitors taken 30-60 minutes before breakfast if symptoms occur more than 2-3 times weekly. 1, 2, 3
Lifestyle Modifications: The Foundation
Weight reduction is the single most effective lifestyle intervention with proven benefit on esophageal pH profiles and symptoms, and should be the first recommendation for all overweight or obese patients (BMI ≥25 kg/m²). 4, 1, 2, 3 The evidence shows dose-dependent benefits, with significant symptom reduction in those who achieve weight loss. 4, 3
Positional and Timing Strategies
Elevate the head of the bed by 6-8 inches (not just using pillows) for patients experiencing nighttime heartburn or regurgitation, as this reduces esophageal acid exposure time and improves acid clearance. 1, 2, 3 This intervention shows 50-70% reduction in symptom severity. 3
Avoid lying down for 2-3 hours after meals to reduce esophageal acid exposure by 30-50%. 4, 1, 2, 3
Sleep in the left lateral decubitus position rather than right side or supine, as this may reduce reflux episodes. 1, 2
Avoid late evening meals and ensure at least 2-3 hours between the last meal and bedtime. 2
Dietary Modifications
Identify and avoid individual trigger foods through a detailed dietary history rather than broadly restricting all potential triggers. 1, 2, 3 Common triggers include alcohol, coffee, chocolate, fatty foods, spicy foods, citrus, and tomato products. 1, 2
Limit fat intake to ≤45 grams per day, particularly important for bile reflux. 2
Important caveat: The evidence does not support broadly recommending all lifestyle modifications to every patient, as this leads to poor compliance. 2 Focus on the interventions with the strongest evidence (weight loss, bed elevation) and individualized trigger food avoidance. 1, 2
Pharmacologic Management Algorithm
Step 1: Occasional Symptoms (Less than 2-3 times weekly)
Start with as-needed antacids, which provide relief within minutes with 80-90% response rates. 3
Alternatively, use low-dose H2-receptor antagonists (such as ranitidine 150 mg), which provide relief within 30-60 minutes lasting up to 12 hours, with a number needed to treat of 2-3. 3, 5
Step 2: Frequent Symptoms (More than 2-3 times weekly)
Initiate once-daily proton pump inhibitor therapy (omeprazole 20 mg or equivalent) taken 30-60 minutes before breakfast for 4-8 weeks. 1, 2, 3, 6 PPIs are the most effective first-line pharmacological treatment, superior to H2-receptor antagonists and placebo. 1, 2
Critical timing error to avoid: PPIs must be taken 30-60 minutes before meals, not at bedtime or with meals, as failure to optimize timing reduces efficacy by 30-50%. 3
Symptomatic relief commonly occurs within 24 hours of starting therapy. 5
Step 3: Persistent Symptoms After 4 Weeks
Escalate to twice-daily PPI dosing (one dose before breakfast and one before dinner) if symptoms persist after 4 weeks of optimized once-daily therapy. 1, 2, 3
Consider adding alginate-containing antacids for breakthrough symptoms, which provide relief in 30-50% of patients. 1, 3
For nocturnal symptoms specifically, consider adding bedtime H2RA, though tachyphylaxis limits long-term use. 1, 3 However, the American College of Gastroenterology does not recommend adding nocturnal H2RA to twice-daily PPI as standard practice, as there is no evidence of improved efficacy with this combination. 1
When Home Management Is Insufficient
Red Flags Requiring Medical Evaluation
Seek medical evaluation if experiencing:
- Dysphagia (difficulty swallowing) 1
- Unintentional weight loss 2
- Anemia or bleeding 2
- Persistent symptoms despite 4-8 weeks of optimized PPI therapy 2, 3
Understanding Treatment Failure
Common pitfall: 20-42% of patients demonstrate partial or complete lack of response to PPI therapy. 7 However, many of these patients either do not have GERD, have not been adequately treated (wrong timing, insufficient dose), or have poor compliance. 7
If symptoms persist after 4-8 weeks of twice-daily PPI taken correctly (30-60 minutes before meals), this warrants endoscopy or pH monitoring rather than further empirical treatment escalation. 1, 2, 3
Special Considerations
Extraesophageal Symptoms
Symptoms such as chronic cough, hoarseness, throat pain, and asthma are less likely to respond to standard therapy (20-40% response rate) and often are not caused by GERD. 4, 1, 3 These require investigation for non-GERD causes before extensive testing. 4, 3
Functional Heartburn
Patients with normal endoscopy, normal esophageal acid exposure, and negative symptom association have functional heartburn, which responds poorly to PPIs. 4, 8, 9, 10 These patients require different treatment algorithms including pain modulators rather than escalating acid suppression. 4, 9, 10
Medications to Avoid
Do not use metoclopramide as monotherapy or adjunctive therapy for heartburn due to its unfavorable risk-benefit profile, including risk of tardive dyskinesia (number needed to harm of 5-10). 2, 3
Maintenance Therapy
Once symptoms are controlled with PPIs: