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How to deal with heartburn

When to treat it on your own and when to get help

Consumer Reports on Health: August 2012

Nearly everyone has experienced heartburn after eating a sumptuous or simply oversized meal. For many, the distress dies down within an hour or so— with or without the help of Rolaids or Tums—making it seem like nothing to worry about.

But the millions who suffer from frequent heartburn might actually have a chronic condition called gastroesophageal reflux disease, or GERD. Left untreated it can damage the esophagus and even lead to cancer.

Lifestyle changes and over-the-counter medication can provide relief for many people, but it’s important to know if your symptoms are serious enough to warrant a trip to the doctor. And when should you turn to potent medications called proton pump inhibitors (PPIs) to extinguish the flames?

More than 50 million people in the U.S. experience heartburn every month, and about 15 million have daily flare-ups, according to the National Institute of Diabetes and Digestive and Kidney Diseases. The cost of treating the condition can quickly add up. The average person with GERD, a related ailment, spends an estimated $3,355 a year on medication and other treatments to help keep symptoms under control. Obese people, smokers, and pregnant women are more likely to suffer from GERD, but it can strike otherwise healthy men and women at any age.

How heartburn happens

When you swallow food, it travels down your throat to your esophagus into your stomach, which produces acid to help break it down so that it can be  digested. Your lower esophageal sphincter, a muscle at the entrance to your stomach, is supposed to close after the food passes through to keep stomach acid from going into the esophagus. But if it doesn’t, and acid reaches the esophagus (along with food), you’ll feel a burning sensation. It usually starts just below your breastbone and can radiate into your throat. You might also notice a sour or bitter taste in your mouth or throat.

Occasional heartburn is generally not worrisome or dangerous, and can be relieved with diet and lifestyle changes and, if necessary, over-the-counter antacids or other medications. However, if you have heartburn twice a week or more, and it recurs for weeks or months, or if you frequently regurgitate food (with or without heartburn), consider seeing your doctor to be checked for GERD.

In contrast to occasional heartburn, GERD can be dangerous. Over time, the refluxed acid can inflame and erode the lining of the esophagus, resulting in esophagitis. You may feel a chronic soreness in your lower throat or chest. Most cases of esophagitis are relatively mild, but when it is left untreated, bleeding, scarring, and narrowing of the esophagus can occur, making eating and swallowing painful and difficult. People who have uncontrolled GERD for years have a higher risk of developing cancer of the esophagus, though it’s rare.

Fortunately, changes in your diet and lifestyle might be all you need to alleviate the problem. Those measures include eating smaller meals, not lying down for at least three hours after eating, losing weight if needed, and avoiding alcohol. Certain food and beverages can trigger heartburn in some people, such as citrus fruit, chocolate, coffee or other caffeinated beverages, fried food, garlic, onions, spicy or fatty food, and tomato-rich food, such as marinara sauce, salsa, and pizza.

Drinking alcoholic beverages may increase GERD symptoms, which over time can cause damage to the lining of the esophagus. Symptoms may resolve after you stop drinking. Smoking weakens the lower esophageal sphincter muscle and increases the risk of GERD (and other diseases), so if you smoke, you should quit.

To help reduce heartburn flare-ups while you’re asleep, try placing wood blocks beneath your bedposts to raise the head of your bed 6 to 8 inches. Avoid wearing tight clothing or belts that push on your abdomen, since compressing that area can contribute to reflux.

Medication

If diet and lifestyle changes don’t help, it might be time to try an antacid, such as Maalox, Mylanta, Rolaids, or Tums. Some people might need something stronger to relieve their symptoms. In that case, try an acid-reducing H2 blocker such as famotidine (Pepcid AC and generic), nizatidine (Axid AR), or ranitidine (Zantac 75, Zantac 150, and generic). Those drugs help about half of sufferers and can be bought over-the-counter. You might also consider using an over-the-counter PPI, such as lansoprazole (Prevacid 24HR), for up to two weeks to see if it eases your symptoms.

If you’ve tried these options and still have heartburn at least twice a week for several weeks, it’s time for a doctor to determine if you have GERD and if it has damaged your esophagus. If you have the condition, he or she will probably recommend that you have an upper endoscopy. This procedure, done under light anesthesia, involves the insertion of a lighted, flexible endoscope tube into your throat and down into the esophagus. The doctor can also use the endoscope to do a biopsy to test for cancer or Barrett’s esophagus, which can lead to cancer.

If you have GERD your doctor will probably prescribe a PPI, such as esomeprazole (Nexium), lansoprazole (Prevacid and generic), or omeprazole (Prilosec and generic). Those popular drugs substantially reduce the amount of stomach acid produced, making the contents of your stomach less erosive. If there’s already damage to your esophagus, reducing the amount of acid can help it heal.

But many doctors also think that PPIs are overused, a problem that is exacerbated by heavy advertising from pharmaceutical companies. The federal Agency for Healthcare Research and Quality (AHRQ) also noted a widespread overuse of PPIs (as well as other drugs used to treat GERD) in a September 2011 report. Ads have helped propel those drugs to top-selling slots among all prescription medication.

One PPI, Nexium, racked up $6.2 billion in sales in 2011, making it the third highest-selling prescription drug in the U.S. last year, according to IMS Health, an industry group that monitors drug sales. But studies have found that up to 70 percent of people who take a PPI may not have GERD and may not need such a potent, expensive medication.

PPIs can also cause serious side effects, including an increased risk of diarrhea associated with Clostridium difficile, an acute, sometimes chronic ailment that can lead to severe intestinal problems and, in rare cases, death. Long-term use can deplete magnesium levels, which can trigger muscle spasms, an irregular heartbeat, and convulsions. Other potential side effects include a higher risk of pneumonia and certain bone fractures, including breaks in the wrist, forearm, and spine.

PPIs can also interact with other medication, so before you take one, make sure it’s compatible with other drugs you take. One of the most serious interactions occurs with omeprazole (Prilosec and generic) and clopidogrel (Plavix), a blood thinner used to reduce the risk of clots that could lead to a heart attack or stroke. According to the U.S. Food and Drug Administration, omeprazole can reduce the effectiveness of Plavix by about half, increasing the risk of a heart attack or stroke. Nexium and the H2 blocker cimetidine (Tagamet and generic) might also interact with Plavix in the same way as Prilosec.

If you need a PPI, Consumer Reports’ Best Buy Drugs report recommends first trying an over-the-counter option, such as generic omeprazole, Prilosec OTC, or Prevacid 24HR. At less than $1 a day, they cost almost one-tenth the price of several of the prescription alternatives. And for most people, they are as effective as the prescription drugs. But check with your insurance provider to see if over-the-counter PPIs are covered. If not, it may be less expensive to get a prescription PPI because it might only cost you a $5 to $10 drug co-payment.

There’s no clear answer about when to consider stopping a PPI, because that decision varies. For some people with GERD, symptoms go away after drug treatment and lifestyle changes, or they recur only periodically. Others appear to have a lifelong battle with GERD, so they may need to continue taking a PPI daily to keep symptoms under control. Some people might even need to consider surgery.

If you are diagnosed with GERD and are given a PPI prescription, ask your doctor how long you should take the medicine. After a few weeks or months, you may be able to slowly taper off the drug and eventually stop taking it without issue. If your symptoms return, you can often resume taking the medicine.

Considering surgery

If lifestyle changes and medication haven’t helped, then surgery may be an option. The standard procedure for GERD is laparoscopic fundoplication, in which the upper part of the stomach is sewn around the lower part of the esophagus.This is intended to help strengthen the sphincter muscle. It often helps relieve reflux symptoms and decrease the use of heartburn medication, according to the 2011 report from the AHRQ.

But some people who have surgery may still need to take drugs. Also, serious side effects can arise from the surgery, including infections, a hernia, and difficulty swallowing. So laparoscopic fundoplication should be used only as a last resort.

Choosing the right heartburn remedy

Medication: Antacids (Maalox, Mylanta, Rolaids, Tums, and generics) When appropriate: For occasional heartburn (less than twice a week). You should also make lifestyle changes, such as avoiding food that triggers heartburn and eating smaller meals.


Medication: H2 blockers (Pepcid, Zantac, and generics) When appropriate: For occasional heartburn not relieved by antacids and lifestyle changes, or before eating a known heartburn trigger.


Medication: Proton pump inhibitors (Prevacid, Prilosec, and generics) When appropriate: For frequent heartburn not relieved by lifestyle changes, antacids, or H2 blockers. After two weeks of use, check with your doctor to determine if you have GERD


Editor's Note: This article first appeared in the Consumer Reports on Health newsletter.

   

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