Help for Heartburn

Heartburn, also called GERD (gastro-esophageal reflux disease), is miserable.  To review what causes it, see this post.  Now, let’s talk about how to make it better.  I know this subject better than I’d like to, and if you suffer from heartburn, I feel your pain:  I, too, am a reluctant member of the GERD herd.

So. what kind of heartburn do you have?  Let’s look at the whole spectrum, ranging from the occasional unwelcome guest to the toxic constant companion.

First scenario: You’re minding your own business, it’s late at night, you have an attack of heartburn, and you don’t have any medicine. What can you do? Well, you can go old-school: make your own antacid by mixing up 1/2 teaspoon of baking soda in half a glass of water. It will neutralize the acid. But as with any antacid (see below), the effect won’t last forever. Some foods are soothing for the acid-inflamed stomach, as well. Soda crackers (like Saltines) have baking soda, and can help soak up the acid. Also, apples are your friend. Just eating a plain old apple can help disarm the stomach acid. Some people swear by apple cider vinegar:  A tablespoon, mixed with a tablespoon of honey in a cup of warm water can provide temporary relief, as well.  My go-to, if I’m feeling the burn and need help right away:  a shot of something carbonated.  Mexican Coca-Cola (with cane sugar, not high-fructose corn syrup) is my personal favorite, but any seltzer or soda water will provide temporary relief.  The bubbles are good.

But this is just emergency stuff, best for the occasional flare-up.  If you have severe or persistent GERD, you need to move into the realm of acid-fighting medicines.

The next scenario:  It’s not your first rodeo. You have noticed that you’ve been having heartburn lately, so you’ve bought some Tums. Well, okay. The problem here is that Tums contain calcium carbonate. They will buffer the acid and give you immediate relief – and some people do okay just taking an occasional Tums.  But for those of us with persistent GERD, the calcium actually causes the acid level to bounce back — higher than it was before you took the Tums. This is called rebound hyperacidity. “So an hour later, you are making more acid than you did before, and you’re taking another Tums,” says University of Virginia gastroenterologist Mark Worthington, M.D. (Disclaimer: I happen to be married to Mark, an excellent gastroenterologist and caring physician.)

You probably don’t want to live this way, with one surge of stomach acid following another in big, unpleasant waves. Tums are not a good long-term solution for chronic reflux, so let’s move on to drugs.

Other antacids include Rolaids, Maalox, Mylanta, and Gaviscon. These are different from Tums in the chemicals they contain (the names for these compounds end in oxide and ate): Rolaids have calcium carbonate magnesium hydroxide. Maalox and Mylanta contain aluminum hydroxide and magnesium hydroxide, and Gaivscon has aluminum hydroxide and magnesium carbonate. You can get these kinds of antacids as chewable tablets, dissolving tablets, as chewing gum, and in a liquid form. Some of them have a bonus ingredient, like simethicone, which may help subdue the gas bubbles percolating in your stomach; Gaviscon’s bonus ingredient is alginic acid, which foams and helps keep what’s in your stomach from creeping back up the esophagus.  “These work for people with heartburn that is occasional and not too severe,” says Mark, “although the magnesium can cause loose stools (diarrhea).”

However, if you have more frequent bouts of heartburn, you need to move on to the next level in the acid-resisting fortress:

Acid Reducers, also called H2 Receptor Antagonists, or H2 Blockers. These drugs end in “idine,” and include Pepcid (famotidine; there are many generic famotidine 20 mg brands available) and Tagamet (cimetidine), not often used because it has interactions with other medications).  (Personal note, Pepcid or its generic equivalent works for me.  My GERD is controlled with one 20 mg famotidine, twice a day.)  Dual-action Pepcid Complete (or generic equivalent, containing 10 mg famotidine plus calcium carbonate and magnesium hydroxide) combines an acid reducer with antacids.  This gives immediate relief and then keeps the acid down.

Interestingly, although they’re high on the ladder of heartburn remedies, doctors don’t even think of acid reducers as particularly high-powered. “These are okay reflux drugs,” says Mark. “They don’t suppress acid as much as proton pump inhibitors or PCABs  (see below) do, which some people see as a benefit.”  Why a benefit? Well, if you can get away with taking this level of drugs and having your symptoms controlled, you can still get some of the good out of stomach acid. Long-term lack of stomach acid can lead to bacterial overgrowth (an excess of bacteria) in the small intestine, and a deficiency of magnesium, iron, calcium, vitamin B12, and some trace minerals — because it turns out that you need some acid to absorb them.

The Big Guns

Now we move to the high-powered drugs:  Proton Pump Inhibitors (PPIs) and potassium channel acid blockers (PCABS).

PPIs are the “prazoles,” and include:  Prevacid (lansoprazole), Prilosec (omeprazole), Protonix (pantoprazole), Nexium (esomeprazole), Dexilant (dexlansoprazole), Aciphex (rabeprazole). The over-the-counter PPIs are at lower doses, and are meant to be taken for two to three weeks.  They can be taken for longer than that, but if you keep buying more of these 14-day packs, you should consider seeing a gastroenterologist.  PPIs don’t dry up all the acid in your stomach.  Instead, as Mark says, “In typical doses, they take the battery acid in your stomach and turn it into vinegar-strength acid,” and give your poor inflamed esophagus a chance to heal. More on this in a minute.  “If the reflux goes all the way to the airway (laryngopharyngeal reflux, where the acid bubbles up to your throat or even nose), we will give a higher dose of a PPI and block all the acid,” notes Mark, “but there are side effects,” including bacterial overgrowth, nutritional deficiency, kidney damage, and loss of bone strength.  In severe cases, the best option may be surgery (see below).

Note:  PPIs are not meant to be taken continuously over the long run.  The idea is to take a prescription PPI for two to three months when you have had a bad bout of GERD with a lot of esophagitis, get you through that, and then wean you off or move you to something less powerful like Pepcid – or to nothing at all.

What about the risk of dementia with PPIs?  “That really appears to be related to vitamin B12 deficiency,” says Mark, “which tends to occur after about two to five years on the drug.”  So if you are on a PPI for more than a year, make sure your doctor checks your level of vitamin B12, and to be on the safe side, take a vitamin B12 supplement.  “You need stomach acid to absorb B12,” Mark explains, “but if you take enough of it, using a vitamin supplement, your body will manage to absorb some. The good news is that this cognitive impairment is usually reversible when the vitamin B12 is repleted.”

Still, the idea is not to take a PPI forever, and if your symptoms don’t get better, one option is surgery (see below).  But wait!  Your pool of options just got bigger.  There is a brand-new category of drugs to treat GERD:  PCABs.

PCABs are “potassium-competitive acid blockers.”  For now, they are available only by prescription, and they’re expensive (several hundred dollars a month).  The first PCAB on the market is called Voquenza (vonoprazan).  “It blocks acid, but it works in a different way than a PPI,” says Mark.  “The nice thing is, there’s no strict association with taking it on an empty stomach – unlike a PPI, which you need to take when the stomach is empty and there’s acid present, so the drug has access to the acid pumps.  Voquenza doesn’t take days to work, either, compared to PPIs, which require a few days to get to their peak effect – so it may have potential in the future for intermittent dosing.”  Although there is only one PCAB on the market in the U.S., others are available in Japan, and may one day come to the U.S. market.  As Mark says, “Competition is good,” and maybe this will lower the cost of these drugs.

Protecting the Beleaguered Esophagus

“Your esophagus can only take so much,” as Mark explains.  “So. if your doctor thinks you need a proton pump inhibitor, you should take it. Because if you don’t treat GERD, it can damage your esophagus.”

Inflammation in the esophagus, called esophagitis, hurts, and makes it difficult to eat.  Worse, long-term esophagitis can lead to a condition called Barrett’s esophagus — which, in turn, can lead to cancer. This is diagnosed with an upper endoscopy, and the good news is that there is treatment for it, called radiofrequency ablation. “We basically zap the lining of the esophagus with radio waves,” says Mark. “This causes a very defined, superficial burn, and the Barrett’s tissue sloughs off. It’s like getting a sunburn in the esophagus, but it can save your life.”

Long-term esophagitis can lead to a condition called a Schatzki ring. “This is a shelf of scar tissue between the stomach and esophagus,” says Mark, “and food can get hung up on that when you swallow. It’s called ‘steakhouse syndrome,’ because it’s usually a big piece of steak that gets stuck in there. You feel like you’re having a heart attack, but it’s really just the esophagus having a spasm around the food.”

Long-term damage to the esophagus can also lead to development of a stricture — more scar tissue, but instead of a ring, it’s a progressive narrowing, so that food can’t go down very easily. This, too, is treatable: the stricture can be opened up during upper endoscopy, as a gastroenterologist makes tiny cuts in the scar tissue to relax its stranglehold on the esophagus.

Finally, there is surgery, a procedure called fundoplication:  taking the top of the stomach and wrapping it around the esophagus to create an artificial valve — so that what happens in the stomach stays in the stomach. “It works pretty well,” says Mark, although with this procedure in place, “you can’t burp and you can’t vomit, because if you do, you could rip the stitches.” The fundoplication may not last forever. “They do tend to stretch a little over time, but for people with the most severe reflux – reflux that is not controlled with medication, or when people can’t get off a PPI because their symptoms are so bad – it is not an unreasonable thing to do.”

If you keep having heartburn more than twice a week, what should you do? Well, you can try the lifestyle and diet changes written about here. If those don’t make your symptoms better, you can start on the remedies discussed above, but if these don’t help, or if you are taking a PPI more than twice a week, the best thing you could do would be to get an upper endoscopy (done by a gastroenterologist, so you’ll need a referral from your primary care doctor), to make sure you don’t have any damage to the esophagus that needs more serious treatment.

In addition to the book, I have written about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org.  The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  I firmly believe that knowledge is power.  Saving your life may start with you going to the doctor and knowing the right questions to ask.  I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease.  Many doctors don’t do this, so it’s up to you to ask for it.

©Janet Farrar Worthington