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If you have horrible, persistent heartburn, relief can be as simple as popping a pill once or twice a day. Proton pump inhibitors, or PPIs, put the kibosh on the stomachs acid production, keeping gastric juice from backing up into the esophagus and causing pain. (PPIs include brand names such as Nexium, Prevacid, Prilosec, and Protonix.)

But they dont work for everyone. Even if youre one of those people who does well on PPIs you can still have “breakthrough” symptoms from time to time, when heartburn flares into an agonizing episode.

Studies suggest that up to 40% of people with heartburn who take a PPI once a day still experience heartburn or other breakthrough symptoms once in a while, says David A. Johnson, MD, a professor of medicine and the chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Va., and past president of the American College of Gastroenterology.

Find out why heartburn meds can let you down—and what to do about it.

Why heartburn drugs can fail
Its possible that PPIs arent curing your heartburn because youve been misdiagnosed, says gastroenterologist Joel Richter, MD, the chair of the department of medicine at Temple University, in Philadelphia.

Many conditions cause symptoms that mimic those of gastroesophageal reflux disease (GERD), the medical term for persistent acid reflux that damages the esophagus. Muscle contractions, stretching, and non-acidic reflux in the esophagus can all lead to heartburn (the main symptom of GERD), as can unrelated conditions such as heart disease. “There is a big group of people who get put on these medications and dont get better, and most of the time its because they dont have an acid-related problem,” says Dr. Richter.

To find out if your symptoms are due to acid reflux, doctors may perform a test that combines pH monitoring, which measures stomach-acid levels in the esophagus, and impedance testing, which detects the movement of fluid and gas (acidic or otherwise) along the esophagus. This combination can help gastroenterologists distinguish acid- and non-acid reflux episodes. (For instance, if the impedance test registers a reflux but the pH level remains above a certain point, that indicates the reflux contains little or no acid.)

Experts say that if your symptoms are in fact related to acid reflux you should do well on PPIs.

But dont assume that taking medication means you can eat whatever you want, whenever you want. Numerous indiscretions—overloading on fatty or fried foods, say—can trigger breakthrough symptoms. So downing a huge meal, eating late at night, or hitting the sack shortly after a meal can be detrimental to your condition.

“You can eat your way out of these PPIs,” says Dr. Richter. They dont completely knock out acid, he explains. Although it sounds counterintuitive, thats a good thing. Stomach acid plays a key role in sanitizing the digestive tract and in killing off the bacteria that produce nitrosamines, a chemical compound that has been associated with an increased risk of gastric cancer. So a little stomach acid is good; too much, however, can be painful.

Many times symptoms arise because people arent taking their medication correctly or at a time that optimizes its effectiveness, Dr. Johnson explains. “Typically, the proton pump inhibitors are given 30 to 60 minutes before breakfast,” he says. However, some people do better taking two doses a day to stave off nighttime symptoms, he adds.

And missing a pill may readily ignite that familiar burning sensation in the chest and throat and sour taste in the mouth.


What to do when the pain wont stop
Even if youre doing well on PPIs, its a good idea to have a backup plan to cope with breakthrough symptoms.

About 73% of people with GERD taking prescription PPIs say theyre satisfied or very satisfied with the medication, according to a 2009 survey of 617 patients published in Current Medical Research and Opinion and funded by Takeda Pharmaceuticals, the makers of Prevacid. Nevertheless, more than half—56.7% of patients on once-a-day PPI therapy and 65.9% in the twice-a-day group—had heartburn in the week before they took the survey.

Overall, 40% said they resorted to other medications for acid reflux, mostly over-the-counter antacids or histamine-2 (H2) blockers. (Antacids are drugs like Tums; H2 blockers include Tagamet HB, Pepcid AC, Axid AR, and Zantac 75.)

“The most common reason that they were using the over-the-counter medication…is related to incomplete relief of their heartburn,” explains lead author William D. Chey, MD, a professor of internal medicine and the director of the gastrointestinal physiology laboratory at the University of Michigan Health System, in Ann Arbor.

Patients werent reaching for additional heartburn soothers on their own. It turns out that roughly 60% were advised by their doctors to take antacids or H2 blockers to help with residual reflux symptoms, he says.

Breakthrough symptoms may be a particular problem at night. Dr. Cheys team found that most people in the survey, or 82.6%, reported nighttime symptoms in the month prior to taking the survey. Nearly one in four described those symptoms as severe or very severe, while close to half of the patients surveyed said their symptoms were moderate.

5 ways to help your heartburn
Fortunately, there are things acid reflux patients can do to help prevent and minimize breakthrough symptoms.

  • Take your medication as prescribed. If you dont know how and when to take it, call your doctor for specific instructions.

  • Dont hit the sack on a full belly. Lying down within three to four hours of consuming a large meal, particularly a late-evening feast, could spell trouble. "My big push is to keep the patients away from late eating, large meals and recumbency," Dr. Johnson says. Such a triple threat may pose too large of an insult on the body, one that even PPIs—the gold standard in GERD treatment—cant handle. For nighttime symptoms (especially regurgitation of fluid back into the esophagus or mouth), Dr. Johnson suggests elevating the head of the bed with some blocks or using a bed wedge to elevate the upper torso.

  • Shed a few pounds. A 2006 study in the New England Journal of Medicine found a strong link between GERD symptoms and body mass index, even in women of normal weight. Using data from a survey of more than 10,500 participants in the Nurses Health Study, researchers from Boston University and Harvard Medical School found that overweight and obese women were two to three times as likely as thinner women to have frequent reflux symptoms. Moderate weight gain, even in normal-weight people, may exacerbate reflux symptoms, according to the study. "A reduction of even 2.5 pounds may be enough for some patients to decrease or eliminate their reflux symptoms," Dr. Johnson points out.

  • Try an over-the-counter drug. Drugs like Tagamet HB, Pepcid AC, Axid AR, and Zantac 75 are very effective in knocking out acid, Dr. Richter says. The paradox is theyre not very effective when taken daily, because people develop a tolerance to the drug, he adds. "What I suggest to my patients is that they take an over-the-counter H2 blocker when they have their breakthrough symptoms," he says. "That seems to give them better control."

  • Recognize the foods that trigger your breakthrough symptoms. If jalapeños or onions always get the better of you, consider skipping those items. If youre going out for a spicy Mexican meal, taking an H2 blocker an hour or so before may help ward off your symptoms before they start.
“If people are having residual symptoms several times per week, and certainly if theyre having residual symptoms to the point that its interfering with their ability to sleep…or function on a day-to-day basis, they should definitely talk to their physician about it,” Dr. Chey advises.

Last updated: Aug 31, 2009