Heartburn is the most common gastrointestinal complaint in the world¹.  Pooled data from 31 articles suggest that 25% of people in Western societies experience heartburn at least monthly, 12% experience heartburn at least weekly and 5% experience heartburn daily².   Heartburn during pregnancy is considered quite normal and occurs in approximately 30 to 50% of this population³. 

People who suffer from heartburn often experience a burning sensation behind their breastbone. This sensation may or may not radiate up towards their throat. One may even experience slight regurgitation, or the presence of acidic fluid in the mouth. Heartburn occurs for many sufferers after meals and may be aggravated by lying down.

Heartburn is not a diagnosis or disease, it is a symptom. Often it is a symptom of one of three disorders: GERD (gastroesophageal reflux disease), dyspepsia or peptic ulcer disease. It is important to know that frequent or painful heartburn can be a sign of a more serious problem like esophageal cancer.  However, very few people seek medical advise and choose to ignore the symptoms or try to treat this type of heartburn with over-the-counter remedies^1,4.

When in doubt as to whether or not you should self-treat your heartburn, you can always ask your pharmacist. By explaining your symptoms and the frequency of these symptoms to your pharmacist, you and he/she will be able to determine if your heartburn needs further medical intervention or if it can be safely treated over-the-counter.  Examples of times you should NOT self-treat your heartburn are listed below:

Table 1     Do NOT Self-Treat your Heartburn If:⁶

Self-Treatment Options for Heartburn

If after talking to your pharmacist you decide that it is ok to self-treat your heartburn, there are many treatment options available.

Lifestyle Modifications

Many patients are able to manage their frequent or occasional heartburn with diet and lifestyle modifications.  However, the most recent guidelines for diagnosis and treatment of GERD explain that dietary and lifestyle modifications may benefit some patients but are unlikely to control symptoms in the majority of patients⁵. Still, many patients use dietary and lifestyle modifications in conjunction with over-the-counter medications. The following is a list of suggested lifestyle recommendations.

Table 2     Suggested Lifestyle Recommendations for Patients with Heatburn^5,6,7

There are also foods that patients with heartburn should avoid.

Table 3     Foods Most Commonly Implicated in Heart Burn¹

Finally, many medications can cause or contribute to heartburn. Check with your doctor or pharmacist to see if you are taking any of these medications.

Table 4    Medications That Can Cause or Contribute to Heartburn^1,6,8

General Treatment Principles with Non-prescription Medications 

Occasional Heartburn  

There are two main choices for the self-treatment of occasional heartburn (< 2 days per week); antacids and H2 antagonists. A combination of both may also be used. The choice of which to use depends on the frequency of symptoms, preference and cost.  

Antacids are generally better for more mild symptoms that do not occur as often. H2 antagonists generally work better for more frequent or moderate symptoms. Most of the time, starting with an antacid first is a good idea. If the antacid fails to control symptoms, an H2 antagonist can be tried. One should not exceed use of either of these agents for more than 2 weeks each. A combination of antacid and H2 antagonist (e.g. Pepcid  Complete®) may also be tried, but again, use should not exceed 2 weeks in duration. If 2 weeks use of either of these medications does not provide relief from symptoms, over-the-counter omeprazole may be tried, however, at this point, you should also let your doctor know about your symptoms as he/she may want to evaluate your condition further. One should also remember that dietary and lifestyle modifications should be used in conjunction with any heartburn medication regimen.

Frequent heartburn

For the relief of frequent heartburn (>2 days per week), a combination of diet/lifestyle modifications and over-the-counter omerprazole can be used. If the heartburn has not subsided after a 2 week course of this therapy, you should notify your doctor. 

Over-the-counter Medications

Antacids

Examples of antacids include Tums®, Rolaids®, and Alka-seltzer®. Antacids provide the most rapid relief from heartburn of all of the non-prescription options but their effect does not last as long⁶.  Most antacids are fairly inexpensive. Most antacids work by neutralizing stomach acid.  No one antacid is typically better than another, however, liquid or chewable antacids may work faster than other forms of antacid. Some antacids contain a chemical called alginic acid.  Antacids containing alginic acid are generally considered superior to those that do not contain the compound. Alginic acid combines with saliva to form a foam that floats on top of the stomach contents. This helps to form a barrier that prevents burning when reflux of the stomach contents occurs. You can look to see if a particular antacid formulation has alginic acid in it by looking at the Drug Facts label on the box. Antacids containing alginic acid tend to be more expensive^5,9.  

H2 antagonists

Examples of H2 antagonists include cimetidine 200mg  (Tagamet®), famotidine 10mg or 20mg (Pepcid®), nizatidine 75mg ( Axid AR ), or ranitidine 75mg or 150mg (Zantac®).  H2 antagonists decrease the amount of acid put out by the cells of the stomach. Although all of these medications are generally considered interchangeable, it should be noted that cimetidine is more likely to interact with other medications. Before starting any over-the-counter medication, it is a good idea to ask your pharmacist if it is likely to interact with any medications you are taking. Cimetidine also has the shortest duration of action and has been associated with impotence in men⁶.  It takes longer for H2 antagonsists to start working than antacids. For this reason, H2 antagonists may be taken before a meal if you think you are going to experience heartburn afterwards. H2 antagonists can be taken 15 to 60 minutes before a meal⁵.

Proton Pump Inhibitos (PPI)

Proton Pump Inhibitors (PPI) decrease the amount of acid produced in the stomach. Omeprozole (brand name Prilosec®) is a PPI, previously only available by prescription. It is now available over-the-counter for the treatment of frequent heartburn. It is not intended for occasional heartburn because of the dosing schedule. For frequent heartburn, patients must take one 20mg tablet once daily for 14 days. It may take 1 to 4 days to see the full effect.

Conclusion

Self-treatment of heartburn is appropriate for many patients. It is important to watch for the warning signs of a more serious condition if necessary, however. By listening to your body and working with your pharmacist, you can determine if self-treating your heartburn is right for you and what non-prescription therapy is likely to bring you relief from your symptoms.

REFERENCES

1. Feldman M, Friedman LS, Sleisenger MH, eds. Sleisenger & Fortran’s Gastrointestinal and  Lvier Disease. 7^th ed. Philadelphia , PA : WB Saunders; 2002:95-97, 102-16, 599-622, 761-3.

    

2. Moayyedi P, Axon ATR . Review article: gastro-esophageal reflux disease—the extent of the problem. Aliment Pharmacol Ther. 2005;22(suppl 1):11-19.

    

3. Richter JE.  Review article: the management of heartburn in pregnancy. Aliment Pharmacol Ther. 2005;22:749-57. 

    

4. Richter JE, Gastroesophageal reflux disease. In: Yamada T, ed. Textbook of Gastroenterology. 4^th ed. Philadelphia , PA : Lippincott Williams & Wilkins; 2003:1196-224.

    

5. DeVault KR, Castell DO. Updated guidelines for the diagnosis and treatment of gastroesophaageal refulx disease. Am J Gastroenterol. 2005;100:190-200.

    

6. Zweber A, Berardi RR. Heartburn and dyspepsia. In: Beraardi Nonprescription Drugs. 15^th ed. Washington , DC : American Pharmacists Association; 2006:265-82.

    

7. Kaltenbach R, Crockett S, Gerson LB. Are lifedtyle measures effective in patients with gastroesophageal reflux disease? Arch Intern med. 2006;166:965-71.

    

8. Tailey NJ , Vakil NB , Moayyedi P. American Gastroenterological Associate technical review on the evaluation of dyspepsia. Gastroenterology.  2005;129:1756-80

    

9. Mandel KG, Daggy BP, Brodie DA, et al. Review article: alginate-raft formulations in the treatment of heartburn and acid reflux. Aliment Pharmacol Ther. 2000;14:669-90