What is the best treatment approach for a 64-year-old female patient with no current medication for heartburn, presenting with complaints of severe heartburn?

Treatment of Severe Heartburn in a 64-Year-Old Female

Start with omeprazole 20 mg once daily taken 30-60 minutes before breakfast, combined with aggressive lifestyle modifications including weight loss if overweight and avoiding late meals. 1

Initial Pharmacologic Management

For a patient presenting with "bad heartburn" (suggesting moderate-to-severe symptoms) who is not currently on treatment, proton pump inhibitors (PPIs) are the first-line therapy rather than H2-receptor antagonists or antacids because PPIs are superior for both symptom relief and healing erosive esophagitis. 2

Specific PPI Dosing Strategy

• Start omeprazole 20 mg or lansoprazole 15 mg once daily, taken 30-60 minutes before breakfast 1, 3
• If inadequate response after 4 weeks, escalate to twice-daily dosing (before breakfast and dinner) 3
• PPIs heal erosive esophagitis in 69-71% of patients at 12 weeks versus only 54-60% with H2-blockers 2

Why Not Start with H2-Blockers or Antacids?

While antacids or low-dose H2RAs (famotidine 10-20 mg) are appropriate for occasional heartburn (less than 2-3 times weekly), this patient describes "bad heartburn," suggesting more frequent or severe symptoms. 1 The American Gastroenterological Association gives a Grade A recommendation that PPIs are superior to H2-receptor antagonists for healing esophagitis and symptom relief. 2

Essential Lifestyle Modifications (Not Optional)

These should be implemented simultaneously with pharmacologic therapy:

• Weight loss if overweight or obese (Grade B recommendation) 1, 3
• Elevate head of bed specifically for nighttime symptoms 1, 2
• Avoid eating within 2-3 hours of bedtime and remain upright after meals 1
• Identify and avoid specific trigger foods (coffee, alcohol, chocolate, fatty foods, citrus, carbonated drinks, spicy foods) only if these consistently provoke symptoms 1, 2

Treatment Response Assessment and Next Steps

If Symptoms Controlled After 4-8 Weeks:

• Wean to the lowest effective dose or switch to on-demand therapy with H2-blockers/antacids 4, 1
• Exception: If endoscopy reveals Los Angeles grade B or higher esophagitis, Barrett's esophagus, or peptic stricture, continue at least single-dose PPI indefinitely 4

If Inadequate Response After 4-8 Weeks of Optimized PPI:

This represents potential refractory heartburn (occurs in 20-42% of patients). 5 The approach depends on whether GERD has been proven:

1. If no prior endoscopy: Perform upper endoscopy off PPI for 2-7 days with concurrent prolonged wireless pH monitoring off PPI 4
2. Diagnostic criteria for conclusive GERD: Los Angeles grade B or higher esophagitis and/or acid exposure time (AET) ≥6.0% on 2 or more days 4
3. If physiologic acid exposure (AET <4.0%): This is likely functional heartburn, not GERD—PPIs should be discontinued and neuromodulators considered 4, 6

Critical Pitfalls to Avoid

• Do not continue empiric PPI therapy beyond 8-12 weeks without objective testing if symptoms persist, as 30-50% of PPI non-responders have functional heartburn rather than GERD 6, 7
• Do not assume poor compliance or inadequate dosing first—while these are common causes of refractory symptoms, alternative diagnoses must be excluded 5
• Ensure proper PPI timing: Must be taken 30-60 minutes before meals for optimal efficacy 3
• Do not refer for anti-reflux surgery without proven GERD on pH monitoring, as surgery has no benefit in functional heartburn 6

Adjunctive Pharmacotherapy (If Needed)

If symptoms persist despite optimized PPI therapy and GERD is confirmed:

• Alginate antacids for breakthrough post-prandial or nighttime symptoms 4
• Nighttime H2RA (famotidine 20 mg at bedtime) for nocturnal symptoms, though limited by tachyphylaxis 4
• Baclofen 10 mg three times daily for regurgitation or belch-predominant symptoms 4, 3
• Neuromodulators (low-dose tricyclic antidepressants) or referral for cognitive behavioral therapy/esophageal-directed hypnotherapy if esophageal hypersensitivity suspected 4

Long-Term Management Considerations

• After 12 months of continuous PPI therapy, perform endoscopy with prolonged wireless pH monitoring off PPI to determine if lifelong therapy is truly necessary 2, 3
• Chronic heartburn impairs quality of life in 25-30% of cases, with nocturnal symptoms being particularly troublesome and difficult to treat 8