Over-The-Counter Heartburn Medications: Which to Choose?

Fuchs, Chris 5

Christopher Fuchs Pharm.D. Candidate 2015 St. Louis College of Pharmacy

With the holiday season in full swing many patients are eating large portions of rich foods, which may be delicious, but are not what their bodies are accustomed to. This is a perfect storm for heartburn. Patients usually turn to over-the-counter (OTC) medications before going to their physician for the treatment of heartburn.

Heartburn is defined as a burning pain in your chest, just behind your breastbone that can worsen when lying down or bending over.1 If symptoms persist, heartburn may be a sign of a more serious condition called Gastro-Esophageal Reflux Disease (GERD). If a patient is having any of these symptoms they should see a medical professional as soon as possible:

  • Difficulty or pain with swallowing
  • Unexplained weight loss
  • Chest pain
  • Choking
  • Bleeding (vomiting blood or dark-colored stools)

Otherwise, a patient with mild heartburn is a candidate for OTC therapy. As the medication experts, pharmacists are in a great position to help patients choose the best OTC heartburn medication for them.

The three most common classes of acid suppressors will be covered in this article: antacids, histamine receptor 2 antagonists (H2RA), and proton pump inhibitors (PPI). The advantages and disadvantages of each will be discussed.

Antacids

Antacids are inexpensive medications that work for some patients and have the least amount of side effects compared to other acid suppressors. Antacids work by neutralizing gastric acid. With their short duration multiple dosing is usually required. Antacids should not be taken within two hours before or after most other medications due to their effects on absorption.

Generic Name Brand Name Adverse Effect
Calcium Carbonate Tums, Rolaids, Constipation
Magnesium Hydroxide Milk of Magnesia Diarrhea
Aluminum Hydroxide Mag-Al (combination with Magnesium hydroxide) Constipation, Bad Taste

 

Advantages

  • Quick Onset (5-15 minutes)
  • Few side effects
  • Can be taken as needed

Disadvantages

  • Drug interactions with tetracyclines, ferrous sulfate, isoniazid, quinidine, sulfonylureas, and quinolone antibiotics

o   Should not be taken within two hours before or after other medications

  • Short Duration

o   1 to 3 hours of relief maximum

H2RA

H2RAs are usually the preferred agent for prophylactic heartburn treatment. H2RAs work by blocking the histamine H2 receptor on parietal cells; thus, suppressing acid secretion. H2RAs can be used with antacids to combine the antacid’s quicker onset with the H2RA’s longer duration. A good candidate for this therapy option would be a patient that enjoys spicy food, but knowingly gets heartburn after eating it. Taking an H2RA with the meal could prevent this patient’s heartburn.

Generic Name Brand Name Adverse Effect
Famotidine Pepcid AC HeadacheConstipation

Diarrhea

Nausea

Vomiting

Ranitidine Zantac
Nizatidine Axid
Cimetidine Tagamet

 

Advantages

  • Quick Onset: 1-2 hours
  • Duration: ~ 9hours
  • Few drug interactions (excluding cimetidine)
  • Few common adverse effects
  • Can be taken with Antacids
  • Can be taken as needed

Disadvantages

  • Drug interactions with cephalosporin antibiotics, antivirals, and itraconazole
  • Cimetidine inhibits CYP enzymes leading to numerous drug interactions

PPI

Proton Pump Inhibitors are the gold standard for chronic heartburn.3 PPIs work by irreversibly blocking the hydrogen/potassium adenosine triphosphatase enzyme system (proton pump) in parietal cells. This blockade leads to a decrease of hydrogen ion secretion by the parietal cells: therefor, leading to an increase in stomach pH. OTC PPIs should be taken as a two week trial. All PPIs should be taken 30 minutes before breakfast on an empty stomach daily for the two week trial. Since PPIs have a long onset, it is important to remind the patient that it might take a day or two for full effect and to take them every day of the two weeks.

 

Generic Name Brand Name Adverse Effect
Omeprazole Prilosec OTC HeadacheAbdominal pain

Diarrhea

Flatulence

Nausea

Vomiting

Lansoprazole Prevacid 24HR
Esomeprazole Nexium OTC

 

Advantages

  • Long Duration: ~ 24 hours
  • Taken once a day
  • Best results
  • Few drug interactions

Disadvantages

  • Doesn’t work as needed
  • Long Onset: takes 1 to 2 days for full effect
  • More side effects than others

All acid suppressors should not be used for more than two weeks. If a patient’s heartburn returns after use of acid suppressors for two weeks, they should seek medical help as soon as possible. Heartburn that lasts longer than two weeks can be a sign of a serious underlying disease. Mild heartburn can be easily treated with OTC medications. It is important to encourage patients to utilize their pharmacists. Pharmacists can play a key role in helping a patient select the correct acid suppressor for his or her heartburn. Using OTC products will also help the patient avoid unnecessary doctor or urgent care visits. As the holidays continue with all of the turkey, Christmas ham, and pie, it is important to talk to patients about heartburn and encourage them to take action with OTC products.

Christopher Fuchs
Pharm.D. Candidate 2015
St. Louis College of Pharmacy

References

  1. Disease and Condition Heartburn. Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/heartburn/basics/definition/con-20019545.Updated: August 7, 2014. Accessed December 3, 2014.
  2. Lexicomp Online®, Lexi-Drugs® , Hudson, Ohio: Lexi-Comp, Inc.; December 3, 2014.
  3. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108(3):308-28.

Tweet with @TheMPA