Last updated: Jun 01, 2009

Do you have heartburn that just won't quit? You may have gastroesophageal reflux disease (GERD), a condition in which stomach acid routinely backs up in the esophagus. The most obvious and painful symptom of GERD is killer heartburn.


Because you can grab over-the-counter heartburn remedies quickly at a drugstore without a doctor's visit or a prescription, these are often the first line of defense against GERD.

But a glance down the pharmacy aisle shows a vast array of choices, including Tums, Rolaids, Zantac, and Pepcid, to name just a few. (The latter two are also available in high-dose prescription versions.) Which product is the right one to help you quash the burning pain in your chest?
 
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Although it's easy to feel overwhelmed by the options, a better understanding of your heartburn triggers can help you sort through the clutter and choose the right GERD remedy, says Robynne Chutkan, MD, the founder of the Digestive Center for Women in Chevy Chase, Md.

There are three main categories of over-the-counter heartburn treatment, says Dr. Chutkan, who is also an assistant professor of gastroenterology at Georgetown University Medical Center in Washington, D.C. Each has its own advantages and disadvantages.

Antacids
The best-known class of drugs for curbing heartburn are the antacids—think Tums, Rolaids, and Mylanta. Antacids, which contain the salt form of minerals such as magnesium and/or compounds such as calcium carbonate, curb heartburn by neutralizing acids in the stomach. Some antacids are also a supplemental source of calcium. "These products tend to offer instant relief," Dr. Chutkan says. "If you had corned beef and fries or if you overdid it at dinner and are having symptoms of heartburn, antacids are appropriate. Antacids make more sense for discretionary use and rare episodes of heartburn."

Antacids are very fast-acting, and relieve reflux symptoms (especially heartburn) right away, says Mitchell Cappell, MD, PhD, the chief of gastroenterology at Beaumont Hospital in Royal Oak, Mich. "They are relatively cheap and have been around for 50 years or more, as opposed to other drugs which are newer and more expensive," he says.

Standard antacids such as Mylanta or Maalox also are relatively safe, Dr. Cappell says, although some people who use them may experience diarrhea and constipation. "There are not many side effects and you can take them long term," he says. "But you have to take a lot of antacids because they are not as powerful as other heartburn remedies."

So how long is it safe to take an antacid? Dr. Cappell says he doesn't worry so much about toxicity in patients taking antacids long term but is "concerned about patients munching them all the time because they may be suffering from more severe reflux and need a more potent therapy."

Jonathan Schreiber, MD, a gastroenterologist at Mercy Medical Center in Baltimore sums it up like this: "If your heartburn is brief and related to something you ate, an antacid is fine. It will work quickly and there is little downside, but the negative is that an hour later it's gone from your system. If you have a recurring problem, an antacid is not the answer."

Although they do suppress acid and will make you feel better faster, antacids do not heal the lining of the esophagus. The acid churned out by the stomach can erode the lining of the esophagus over time, which can cause Barrett's esophagus, a precancerous condition that can lead to esophageal cancer.

 
 

Histamine 2 blockers
Another class of heartburn drug that you can buy over the counter is a histamine 2 (H2) blocker. These remedies reduce the amount of acid the stomach produces by blocking histamine, an organic compound that tells your stomach to churn out acid. There are prescription and nonprescription H2 blockers; the choices you can find over the counter include Tagamet-HB, Pepcid-AC, Axid AR, and Zantac 75.

"These drugs have been around since the 1970s and appear to be relatively safe," Dr. Cappell says. They can be used for up to two weeks for short-term relief of heartburn. Side effects may include headache, dizziness, diarrhea, constipation, nausea, and vomiting.

"They are stronger than antacids and their effects are more long lasting," says Dr. Schreiber. "They are also preventive in that they block acid production in the first place."

What does that mean for your heartburn? If you take an H2 blocker, it works for eight to 12 hours. "Some people take these medications twice daily and they can be helpful for mild reflux or heartburn," he says. They help heal the esophageal lining, but not as well as another more potent class of heartburn helpers called proton pump inhibitors (PPI).

Proton pump inhibitors (PPIs)
Available in the United States since 1989, PPIs block an acid-producing enzyme in the lining of the stomach. These drugs also help heal the lining of the esophagus, and do so more effectively than H2 blockers. Prilosec OTC is the only PPI available over the counter; the rest of the drugs in this class require a prescription.

Unlike antacids, PPIs take time to work, Dr. Chutkan says. Some people may not feel better until 24 hours or more after taking them, and that's a lot to ask of someone who feels like their chest is on fire. Side effects may include diarrhea or stomach pain. "PPIs as a group are very effective and safe, but they don't work very quickly," Dr. Schreiber says. "Someone who has heartburn now is probably better off with an H2 blocker or even using an antacid."

Just how effective are PPIs? The best objective measure of the effectiveness of a heartburn remedy is its ability to reverse erosive esophagitis, a condition in which the lining of the esophagus is visibly irritated or injured. Doctors can measure this using an endoscope (a thin, flexible tube with a camera and a light attached), which is passed into the mouth and down the esophagus. Studies have shown that roughly 85% of people with erosive esophagitis are healed when they take a PPI, according to Dr. Schreiber. Far fewer people are healed of this condition with H2 blockers.

 
 

When to see a doctor
Treating heartburn involves more than just popping a pill or munching on a fistful of antacids. These medications work in tandem with lifestyle changes such as cutting out caffeine; consuming smaller, more frequent meals; quitting smoking; and avoiding alcohol, a known heartburn trigger. Other tips that may help extinguish heartburn include not eating after 7 p.m. and propping your head up while you sleep. "You can't expect a pill to work if you are drinking eight cups of coffee and smoking two packs a day," Dr. Chutkan says.

Caffeine relaxes the lower esophageal sphincter, a circular muscle that creates a valve between the esophagus and the stomach. Think of the muscle as a door. "When the door is shut, no acid comes back up. But when the door opens, the acid backs up from stomach to food pipe," Dr. Cappell says. "Caffeine, smoking, and alcohol all tend to make reflux more severe, and they may act by opening this door."

"If you have classic acid reflux or heartburn such as a pain in chest with frequent burping or nausea, it's OK to try over-the-counter remedies—especially if it occurs after a large, fatty meal or late at night," Dr. Chutkan says. Steer clear of the over-the-counter aisle and head straight to your doctor if you have any of these red flags: pain or difficulty swallowing, vomiting, unexplained weight loss, or persistent abdominal pain, she says.

Also call your doctor if your symptoms change in character: If you used to have heartburn, but now food feels like it is stuck in your chest, for example.

"If you have very occasional reflux symptoms—and who doesn't?—it may be reasonable to take over-the-counter medication. But if you are getting it regularly, if it's severe, or if the medication that you took before stops working, definitely see a doctor, and preferably a gastroenterologist," Dr. Cappell says. "The symptoms may be due to another condition, to severe reflux that requires more powerful medicines, or to complications of reflux that require further medical evaluation and treatment."