Choosing The Right Medication For Heartburn

Occasional heartburn is extremely common. It’s often described as a burning sensation in the stomach or lower chest that extends upwards towards the neck. Heartburn also goes by different names depending on who you talk to. Acid reflux, bitter burps, sour stomach, and acid indigestion can all be used to describe what happens when stomach acid travels out of the stomach (where it belongs) and up into your esophagus causing pain and discomfort.

What’s the best product for heartburn? This may surprise you, but most of the products on the shelf work well, so choosing the best product has more to do with how often you are having symptoms, how severe the symptoms are, and how fast you want relief. Keep reading and I will guide you through the process of self-assessment and medication selection. We will go over how and when to take each product, what to expect, lifestyle and dietary changes that can help reduce heartburn symptoms and frequency, and when to get your doctor involved.

Sections

Choosing a medication for heartburn

Overview of Treatment Options

Diet, Lifestyle, and Medications

When to get your doctor involved

References

Choosing a medication for heartburn

To get started, read through the questions below. Pick the response for each question that matches your heartburn the best.

1. How severe are your symptoms?
   • mild - it annoys me but I can ignore it
   • moderate - it bothers me or hurts enough that I can’t ignore it
   • severe - it hurts so much I have missed work or skipped out on activities
2. How frequently are you getting symptoms?
   • 1 - 2 times per week, or just occasionally
   • 2 or more times per week
3. How long have you been having issues with heartburn?
   • less than 3 months
   • 3 months or more

Now let’s use those answers to help steer you towards an appropriate medication.

Mild symptoms 1 - 2 times per week or occasionally (antacids)

If you have mild symptoms an antacid like TUMS, Rolaids, and Gaviscon are my goto choice. They start working in only a few minutes and you can take additional doses as needed to control symptoms. Antacids come in chewable tablets, liquids, and effervescent tablets (the ones that bubble and fizz in water). For the fastest possible relief choose a liquid product like Mylanta. If you are traveling or want something less messy stick with the chewable tablets.

How to take antacids

Follow the package directions for dosing and frequency. Many products will give a range along with a maximum amount that can be taken per day. For example, I typically keep TUMS Extra Strength 750 at home, which says take 2-4 tablets as needed up to a maximum of 10 tablets per day. Start on the lower end of the dose (higher if symptoms are more bothersome) and drink an additional 8oz of water after taking the product. The extra water does a couple of things. It helps spread the medication around in the stomach making it work a bit faster and it also further dilutes the acid in your stomach, which will add to symptom relief.

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What to expect

You should start seeing relief in just a few minutes. If after 5-10 minutes you are still having symptoms you can repeat the dose. Consider drinking an additional glass of water and repeat this dosing process until you have relief (minding the daily dose limit).

Chewable products with calcium carbonate (TUMS, Rolaids, etc.) have a chalky texture to them. If this bothers you you can try something like TUMS Chewy Bites instead. Calcium carbonate products can also cause a build up of carbon dioxide gas in the stomach, making you need to burp to get rid of the gas (or pass gas if it comes out the other end). That’s normal, but if burps are a no-go stick with products like Gaviscon, Mylanta, and Gelusil, which use magnesium hydroxide and aluminum hydroxide to neutralize acid instead.

Antacids that contain magnesium can cause loose stools or diarrhea. Aluminum salts are often included to help combat this problem, but in most cases the magnesium wins. Keep in mind this effect is dose dependent, so you are more likely to see it as you get closer to the maximum daily dose and not everyone who takes magnesium antacids ends up with diarrhea. If you tend to run a bit constipated, magnesium containing antacids may actually be helpful in moving things along.

How long antacids last tends to vary based on what’s in your stomach. On an empty stomach you may need to repeat dosing after an hour or so. On a full stomach you may see benefit for up to three hours.

If you are finding that antacids wear off too quickly or aren’t quite enough you can add on a type of medicine called an H2 blocker. Read the next section if you are in this boat or skip ahead to look at antacid options in detail.

Moderate symptoms 1 - 2 times per week or occasionally (antacid + H2 blocker)

If you have moderate symptoms or are finding that antacids alone are not quite enough consider using an antacid and an H2 blocker. The antacid will take care of your immediate symptoms and the H2 blocker will give you longer lasting relief. The H2 blocker that I recommend trying is famotidine, also known by the brand names Pepcid AC and Zantac 360.^*

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How to take H2 blockers and what to expect

Follow the package directions for dosing and frequency for each product (see previous section for antacids). For famotidine, this is one 10mg or 20mg tablet by mouth along with a glass of water. Unlike antacids, H2 blockers take about a half hour to kick in and last anywhere from 4-10 hours. Famotidine usually lasts about 10 hours so one dose should be enough for a typical case of heartburn, but you could also take a second dose 8 hours later to maintain coverage for the whole day if needed (max 2 per day).²

Side effects with H2 blockers are not common, but headache and loose stools are occasionally reported.

Skip ahead to look at H2 blockers in detail.

Mild or moderate symptoms more than 2 times per week (H2 blocker or PPI)

For frequent heartburn effective treatment involves decreasing the amount of stomach acid your body is producing and making sure you are looking at lifestyle and diet changes that may help. For drugs you have two options. If you aren’t getting symptoms every day you can use an H2 blocker like famotidine as needed (see above). If you have already tried an H2 blocker or are having daily symptoms I would lean more towards taking a PPI (proton pump inhibitor) daily for 2 weeks.

For PPIs we have number of options available (Prilosec, Nexium, and Prevacid) and they come as either tablets or capsules. I don’t actually have a preference of one product over another, so use the table below for a list of options and shop around for the best price.

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How to take PPIs and what to expect

For any of the PPI medications take one by mouth daily in the morning 30-60 minutes before your first meal. The timing is important. PPIs work best when you are actively digesting a meal, but they have to be in your bloodstream to work, which is where that 30-60 minute head start comes from. Of all the heartburn medications PPIs take the longest to work. You will start to see some symptom relief within a couple of hours after taking your first dose, but it may take anywhere from 1-3 days for maximum benefit.

Side effects with PPIs are uncommon, but headache, abdominal pain, nausea, and diarrhea are things to look out for.

You can take a PPI daily for up to 2 weeks. After that time you should take a break. You can repeat a course every 4 months, but if you are finding you need another course before then schedule and appointment with your health care provider to be evaluated.

Skip ahead to look at PPIs in detail.

Severe symptoms and/or frequent heartburn for 3 or more months

If you have severe pain, chronic heartburn, have already tried a number of over the counter options, or have additional symptoms on top of heartburn, skip ahead to see if you would be better off seeing your doctor.

Overview of Treatment Options

The active ingredients in heartburn medications work in one of two ways. They either directly neutralize the acid that’s in your stomach or stop the production of new acid.

Antacids

Medications that directly neutralize acid are called antacids. They also happen to work the fastest, so for relief of heartburn that is happening now antacids are the best choice. Antacids will kick in within minutes and provide relief for 20-30 minutes on an empty stomach and up to 3 hours on a full stomach.

H2 Blockers

H2 Blockers (histamine type 2 receptor antagonists) work by blocking the production of stomach acid. These medications are not absorbed directly in the stomach and instead have to travel through your blood to reach the cells lining your stomach, so it takes 30-45 minutes to start seeing relief. They last anywhere between 4-10 hours.

Examples of H2 blockers are famotidine (Pepcid, Zantac 360), ranitidine (Zantac), nizatidine (Axid), and cimetidine (Tagamet), though only two active ingredients from this list are currently available (famotidine and cimetidine). Cimetidine interacts with a lot of other drugs, so use a product with famotidine unless you talk to your doctor or pharmacist first.

Why aren’t ranitidine (Zantac) and nizatidine (Axid) available?

Lots of ranitidine (Zantac) and nizatidine (Axid) were found to be contanimated with a toxic substance abbreviated NDMA starting in 2019. Afer a number of recalls, the FDA requested removal of all ranitidine products from the market in April 2020. Axid (nizatidine) was discontinued by the manufacturer and ranitdine products have yet to return (as of May 2024). Please note that Zantac 360, the replacement for original Zantac, contains famotidine not ranitidine.

PPIs

Proton pump inhibitors work by permanently blocking the secretion of acid by cells in the lining of the stomach. What’s interesting is that it only works on cells that are actively trying to make acid. So when taking a PPI try and schedule your dose 30-60 minutes before a meal. It will start providing some relief within hours, but you may not see full benefit for 1-3 days. Relief usually lasts for 12-24 hours.

There isn’t any evidence that one particular PPI works better than another, so consider trying the cheapest one first.

Combination products and others

Some products like Pepcid Complete combine multiple active ingredients together for fast and long acting heartburn relief. I prefer the flexibility that buying separate ingredients offers (Tumps + Pepcid), but if you are looking for convenience it’s certainly an option.

Zegerid OTC is a bit of an oddball. Zegerid’s main active ingredient is omeprazole, which is identical to Prilosec, but it also contains 1100mg of sodium bicarbonate as an active ingredient. In theory, the sodium bicarbonate should help with fast acting heartburn relief, but this wasn’t shown in clinical studies. Instead, sodium bicarbonate is listed as assisting in absorption of omeprazole (which it does). I think this was a bit of a miss by the drug company, but they decided to sell it anyway. In addition, the sodium bicarbonate adds a significant amount of sodium to your daily diet (303mg), which is a deal breaker for those on a low salt diet or with conditions like congestive heart failure. Bottom line: Zegerid is a pass for this pharmacist.

Pepto-Bismol is a bit of a Swiss Army Knife for stomach issues. If you have additional stomach symptoms such as upset stomach, indigestion, or diarrhea it may be a good option.

Diet, Lifestyle, and Medications

Certain foods, medications, and lifestyle can all contribute to heartburn.

Diet

It probably comes as no surprise, but there are a number of foods and beverages that can contribute to heartburn. Take a look at the list below.

Are any of these triggers for you? I often get heartburn after eating italian, which usually includes garlic bread and spaghetti sauce (two on the list above). It may be useful to keep a diary or some notes in your cellphone so you can keep track of your heartburn symptoms and how they correlate to what you eat and drink. Once you figure out your own triggers make some changes. For heartburn associated with beverages such as coffee or sodas consider cutting back. If you have evening plans that include some of your triggers you can pretreat with and H2 blocker like famotidine (take 30 min before eating) or bring along TUMS if you start to get symptoms.

Lifestyle

In addition to diet there are lifestyle changes that may help.

1. Losing weight - if you are carrying a few extra pounds losing weight can help reduce heartburn symptoms
2. Stop smoking - smoking is a risk factor for heartburn. If you are a smoker and have heartburn use it as motivation to try and cut back or quit.
3. Change your bedtime habits/routine - for those with evening symptoms be sure to schedule an appointment with your healthcare provider. In the meantime make sure you avoid eating anything 2-3 hours before you sleep. Sleeping on your left side may help (right sided sleeping is associated with more GERD symptoms). If you have an adjustable bed you can elevate your head, but avoid using pillows to prop yourself up. It may make symptoms worse. Instead look at getting a GERD pillow.

Medications

A lot of different medications can potentially cause heartburn, but one of most common culprits are nonsteroidal anti-inflammatory drugs or NSAIDs. Over the counter examples include aspirin, ibuprofen (Motrin, Advil), and naproxen (Aleve). Prescription products include drugs like meloxicam, diclofenac, and indomethacin (there are many more). If you take NSAIDs daily there are some things you need to know. In addition to blocking signals of pain, NSAIDs also block production of mucus and bicarbonate (a natural antacid) in the GI tract. Consider cutting back or talking with your doctor. Long term NSAID use is also a leading cause of stomach ulcers.

Many other families of drugs can contribute to heartburn. I’ve included a short list of drugs below, but there are many others. Check with your doctor or pharmacist if you need help identifying drug related heartburn.

When to get your doctor involved

Most cases of heartburn can be safely treated without getting a doctor involved, but there are a few important exceptions.

If any of these sound like you:

• I used over the counter medication for two weeks, but I still have symptoms
• I used over the counter medication for two weeks, but symptoms came back as soon as I stopped
• I get heartburn multiple times per week and it’s been going on for months (3 or more)
• I’ve tried everything over the counter and nothing works
• or I always seem to get heartburn at night

Schedule an appointment with your health care provider. You can use an over the counter medications to manage symptoms until your appointment, but you need to be seen. Occasional heartburn usually responds well to over the counter medication. Frequent heartburn that has been bothering you for months may mean you have gastroesophageal reflux disease (GERD), the medical term used to describe chronic acid reflux. It’s important to have GERD managed by a physician. Chronic acid reflux damages the tissues in the esophagus and can lead to things like ulcers, esophageal stricture (narrowing of the tube), tooth decay, and increases the risk of esophageal cancer.

If you have heartburn and any of the following:

• unexplained weight loss
• difficulty or pain when swallowing food
• black or tarry stools, vomiting blood or vomit that looks black (coffee ground appearance)
• persistent nausea, vomiting, or diarrhea
• chest pain or pain that radiates to your shoulder, arm, or neck along with shortness of breathe and sweating (call 911 in this case. These are signs of a heart attack.)

Schedule an appointment with your health care provider right away. These are more serious symptoms and need proper medical evaluation.

References