Number 77 August 29, 2008 10,048 Readers
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Over-the-counter (OTC) products are medicines you can buy without a doctor's prescription and we Americans have plenty to pick from. Stop by any Rite Aid, Walgren's, or local pharmacy and you can find multiple products for almost any ailment. This is both a blessing and a curse. In my practice, I find that many patients are confused when confronted by too many choices. They wonder which medications are best and if they really work. Are they getting their money's worth? One aisle that seems to cause much confusion contains all the over-the-counter acid reducing drugs taken for simple heartburn, so-called "acid-indigestion." Read on and see how you can reduce the choices to just three.

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Heartburn and the Three Bears

by Dr. Robert Fusco

Ah, another big, wonderful Sunday breakfast! You pour a second cup of coffee and lie down with the Sunday paper for a relaxing morning on the sofa. Nothing could ruin that perfect scenario, right? Nothing but a painful burning sensation in your chest known as heartburn. If you don't know what heartburn is, you probably have never experienced it. Anyone who has felt that bitter burning sensation in the pit of their stomach which moves up beneath the breastbone knows exactly what I am talking about.

If you have heartburn, you are not alone. Heartburn, or acid indigestion, is one of the most common ailments in the United States, affecting more than 60 million American adults at least once a month. It is estimated that more than 50 million U.S. adults experience heartburn symptoms two or more days a week. And an estimated 25 million adults experience heartburn on a daily basis. Some have more frequent and severe attacks and need to see their doctor. But, most attacks are mild and occur after a spicy meal or late night dinner. These don't require a doctor's care, but what is the best treatment for simple occasional heartburn?

HCl A few words about stomach acid
Think back to high school chemistry class. Remember how you had to wear protective goggles and thick rubber gloves when hydrochloric acid was used in an experiment? That was because hydrochloric acid is very powerful and dangerous when it comes in contact with human flesh. It dissolves it. It's hard to believe that this very same acid is present inside our bodies at all times. Like tiny acid factories, special cells that line the stomach (called parietal cells) produce large amounts of acid every day. When you eat a food like steak, this corrosive stomach acid quickly liquifies and breaks down that meat so that your small intestine can better absorb it.

Why don't we digest our own stomach?
When you think about it, your stomach is also made out of meat. In fact, in some cultures, people consider stomach meat a delicacy known as tripe or Haggis. Why doesn't the hydrochloric acid liquify your stomach lining along with the steak? Fortunately for us, our stomach is lined with a protective mucous barrier that keeps us from digesting ourselves. In effect, the acid never really touches the "meat" of the stomach.

Heartburn: It's just a matter of plumbing
While the stomach is naturally protected from this potent acid, the poor esophagus (or "food pipe") has no mucus barrier to cover and protect its lining from unwelcome acid. So, if acidic stomach contents come into contact with the esophagus, its sensitive skin-like lining can be irritated or injured. The esophagus is protected solely by a one-way muscular valve that lies between the lower esophagus and the top of the stomach. Called the lower esophageal sphincter (LES), this valve stays closed 24/7 preventing acid from backsplashing, or refluxing, up into your esophagus. It only opens temporarily when you swallow to allow food or fluid to enter your stomach and then quickly snaps shut.

esophagus Most heartburn is not caused by an overproduction of stomach acid, but rather by "bad plumbing" - a weak valve. Digestive juices aren't supposed to flow from the stomach upward into the delicate esophagus, but if the LES valve weakens, they can. This backflow is called acid reflux - the most common cause of heartburn. Your esophagus can literally be burned by the acids released by your stomach. Those acids are industrial-strength stuff and are meant to stay where the tough stomach lining can handle them.

Generally, heartburn isn't serious. In fact, small amounts of reflux are normal and most people don't even notice it because the swallowing we do causes saliva to wash the acids right back down into the stomach where they belong. Occasional acid exposure may cause the pain of simple heartburn. When the stomach starts shooting back amounts that are larger than normal, especially on a regular basis or over a prolonged period of time, that's when the real trouble begins. Doctors call chronic heartburn gastroesophageal reflux disease, or GERD. Frequent or severe reflux should not be ignored as it can permanently damage the delicate lining of the esophagus, making it difficult for food to pass and in extreme cases can even turn into a deadly esophageal cancer.

Lifestyle changes
If you are a heartburn sufferer, there are a few simple measures that may help to lessen your symptoms. The simplest is to make changes in your daily habits. Mild and occasional heartburn may not need medication and can be best controlled by lifestyle changes - like watching what you eat. Certain foods can irritate your digestive tract and weaken the LES valve. If you suffer from acid reflux, you should try to avoid them. They include fried and fatty foods, coffee and alcohol, carbonated beverages and products containing chocolate or peppermint.

Whatever you eat, do it in smaller portions. Tempting as it may look, the couch is not your friend after you eat a meal. People who lie down with a full stomach are asking for trouble. Wait at least an hour before you lie down. If you must snooze, try the recliner, but don't recline too steeply. Avoid eating within three hours before bedtime. Acid reflux is yet another of the many harmful consequences of smoking. So if you smoke, stop. People who are overweight are more prone to acid reflux. So losing excess pounds is a good idea, through exercise as well as diet. Loosen the belt. Tight fitting clothing, belts, and girdles can create enough pressure to cause heartburn.

Nighttime heartburn can often be lessened by raising the level of the head of your bed about four-to-six inches above the foot. Gravity may help to hold the acid down in the stomach, where it belongs. Sleeping on the left side has been shown to drastically reduce nighttime reflux episodes in patients. Often these lifestyle changes can markedly reduce symptoms.

Over-the-counter medications - a source of confusion
If lifestyle changes don't stop the heartburn, there are now many helpful over-the-counter medications available. As you stand in the aisle of your pharmacy confronted by dozens of choices, it is easier if you realize that there are really just three basic types of acid-reducing medications to pick from. I tell my patients that it's a three-tier system like the three bears - baby bear, momma bear, and poppa bear. Each is more powerful than the one before it.

tier1, RD "Baby Bear" - Antacids
Available for hundreds of years, over-the-counter antacids in tablet or liquid form can help cool the burn. Antacids do not stop the formation of excess stomach acid or tighten the LES valve. Rather, they rapidly neutralize existing hydrochloric acid through a basic chemical reaction that reduces acidity in the stomach. In this manner, antacids can provide fast relief. Antacids are best for treatment of occasional minor heartburn. They work quickly, but the effects are temporary and wear off in an hour or so. Take a dose about every six hours as needed. Even if you forget to take an antacid during the day, you should take one at bedtime if you suffer from nighttime heartburn. You need to protect your esophagus from the pooling of stomach acids that commonly occurs at night, when you are horizontal for hours on end. Heartburn that occurs during the night causes more damage than daytime heartburn.

Gaviscon, RD Don't overdo it though, because too much antacid can cause constipation or diarrhea. They are not best for severe or frequent heartburn as they don't prevent or heal any acid damage, but merely reduce the symptoms.

While there are many antacids available (Tums, Rolaids, Mylanta, Alka-Seltzer, Maalox, PeptoBismol, Milk of Magnesia), I tell my patients with acid reflux to purchase Gaviscon, or the store brand equivalent. Gaviscon is unique among antacids and is specially formulated for acid-reflux. While it neutralizes existing stomach acid, Gaviscon also produces a protective antacid foam that creates a barrier between the stomach and the esophagus. Gaviscon comes as a tablet or liquid. Gaviscon tablets MUST be chewed and followed by a half-glass of water.

tier2, RD "Momma Bear" - H2-Blockers
Acid in your stomach helps digest food, but your body makes much more than it needs. Shutting down production of stomach acid means there will be less of it waiting to wash upward and burn your esophagus. Pharmacies sell low-dose, over-the-counter (OTC) versions of medications that block stomach acid from forming called H2 (or histamine) blockers. Available since 1979, H2-blockers do not neutralize stomach acid like antacids. Instead they partially reduce the amount of stomach acid by blocking the action of histamine - one of the three paths that stimulate acid production. The four drugs that work by this mechanism in the United States are Zantac (ranitidine), Pepcid (famotidine), Tagamet (cimetidine) and Axid (nizatidine).

H2-blockers take several hours to take effect, but are more effective and longer lasting than antacids. They may relieve symptoms for up to 8 hours. They are best taken 2 times a day and can be taken with or without food. Initially only available by prescription, all H2-blockers are now OTC medications and freely available on your pharmacist's shelf without a prescription. H2-blockers are generally well tolerated and relieve complaints in about 50% of patients.

Gaviscon, RD When you are at the drug store, which do you choose? While I don't believe that generic drugs are always the best choice in this circumstance the generics are equivalent. I tell my patients to save money and purchase the store brand generic form of Maximum Strength Pepcid such as Rite-Aid's Famotidine 20 mg. Acid Reducer.

tier3, RD "Poppa Bear" - Proton Pump Inhibitors
Medications called proton pump inhibitors (PPIs) block the final step in making stomach acid and are the most effective at reducing acid. They virtually shut down the acid pumps in the stomach, leaving just enough acid for normal digestion of food. While PPIs require 1 to 2 days to work, their acid-reducing effect lasts up to 3 days. PPIs are our most powerful drugs and should be reserved for more persistent cases. There are six PPIs available by prescription - Prilosec, Protonix, Prevacid, Nexium, Aciphex, and Zegerid. However, one PPI is available over-the-counter as Prilosec OTC.

The most common side effects are headache and diarrhea. A few studies have suggested long-term daily use of PPIs (over 6 years) may reduce calcium absorption, especially in post-menopausal women. All individuals, men and women, on these drugs should be sure to include an adequate amount of calcium and vitamin D in their diet daily.

Omeprazole, RD Which PPI do I recommend? The choice is limited since at this time there is only one nonprescription PPI available - Prilosec OTC 20 mg. It comes in packs of 42 pills for about $25. It is also available in an equally effective generic form called Omeprazole (oh-MEH-pruh-zole) 20 mg. I tell my patients to save their money and purchase the store brand generic Omeprazole 20 mg if available. It costs less and works just as well. It is best to take all PPIs including Prilosec and Omeprazole on an empty stomach at least 30 minutes before breakfast. The package insert limits use to 14 days without consulting your doctor.

Ask your pharmacist
If the above information is not clear or if their are any other questions about these OTC medications, a great resource that many individuals neglect is their pharmacist. Pharmacists are professionals who have special training in both prescription and non-prescription drugs and can often best advise you at the time of purchase. They can help you sift through the myriad of products, discuss dosages, and ensure that there are no adverse reactions with your current prescription medications. If your pharmacist is too busy to advise you, then find another pharmacy.

When to call your doctor
Most cases of heartburn are more annoying than truly harmful. However, persistent and severe heartburn that is unresponsive to, or returns shortly after OTC therapy, can signal other more serious conditions that may eventually lead to complications. Prolonged or severe heartburn may cause severe irritation, ulcers, precancerous changes (called Barretts Esophagus), and even cancer of the esophagus. Damage to the esophagus can cause a narrow stricture making swallowing difficult. Acid reflux can cause hoarseness, or trigger both acute and chronic coughing, as well as asthma. When acidity spills over from the digestive system into airways, reflux can also damage the lungs.

If you suffer from heartburn symptoms after taking the full course of OTC medications or have taken OTC medication for heartburn for a longer period than stated on the label without consulting a doctor, you need to call your doctor. If you have heartburn that occurs more often than twice a week and can't be controlled by simple lifestyle changes, heartburn that awakens you at night, or any difficulty swallowing, you need to call your doctor. If you need an H2-blocker or PPI drug more than twice a week or if you have chronic symptoms of any degree that have lasted more than a year, discomfort that interferes with your lifestyle or daily activities, or symptoms that have become more severe over time, you need to call your doctor. In most of these circumstances, referral to a gastroenterologist for special evaluation and testing would be appropriate.

Heartburn is a common complaint in our society. Drugs for heartburn are among the most often prescribed forms of medication. In fact, each year Americans spend over $20 billion on medications for heartburn. If you are one of them, I hope that this information will make your next trip to the pharmacy a little less confusing. Simple lifestyle changes are fine in some cases and there are three levels of OTC remedies to help simple heartburn which I recommend.

Gaviscon, RD

Baby Bear Antacid
Works quickly, Weakest, Doesn't last long, Doesn't heal damage, Cheapest
Momma Bear H2 Blocker
Pepcid 20 mg (Famotidine)
Medium Strength. Take twice daily, Lasts 8 - 12 hours
Poppa Bear PPI
Prilosec OTC (Omeprazole)
Most effective, Once daily dose, Takes a day to work, Lasts 1 - 2 days, Heals damage, Most expensive, 14 day limit without doctor's care

Here's something odd...
Prilosec was the first PPI on the market and has since lost patent protection and gone generic. It also has become available in OTC form without a prescription. Usually when a prescription medication becomes available without a doctor's prescription, the dose offered is less than the prescription version. An example would be Zantac 300 mg which was initially available only at a reduced dose of 75 mg per capsule.

However Prilosec was different. This medication now comes in both prescription version and OTC version in both brand name Prilosec and the generic Omeprazole and ALL FOUR ARE THE SAME SINGLE CHEMICAL AND CONTAIN 20 mg.

Brand name by Prescription Prilosec 20 mg $150.00
Brand name OTC nonRx Prilosec OTC 20 mg $18.00
Generic by Prescription Omeprazole 20 mg ?
Generic OTC nonRx Omeprazole 20 mg $16

Sara Parr, RD Sara Parr, RD James Pilla DO Celiac Thank You, Dr. Stanley!
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