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Battling the Burn
Strategies and medications to deal with heartburn

If you have never had heartburn, consider yourself lucky! Many people suffer from it, with symptoms of pain or burning in the chest and a bitter taste in the mouth. Some even have a good idea of when heartburn will strike, depending on what they have eaten. What is heartburn and can anything be done to make it go away?

The stomach is lined with cells that release acid, which helps break down and digest food. Heartburn symptoms appear when stomach contents, including acid, come up into the esophagus. (The esophagus is the tube connecting the throat to the stomach.)

A muscle called the lower esophageal sphincter (LES) is located between the stomach and esophagus. It opens and closes, allowing food to pass through and sometimes expelling (refluxing) acid upward. When acid travels where it does not belong, it can cause burning, pain, and sometimes damage to the esophagus.
Heartburn is often known as the main symptom of GERD, or gastroesophageal reflux disease.

How heartburn happens

Some people have heartburn because the body moves food through the digestive system slowly. This increases the amount of acid produced, in turn affecting the amount of reflux experienced. Heartburn can also develop if too much acid is made. Sometimes, the body produces more acid than actually needed. Certain foods, including onions, chocolate and fat, can spur high levels of acid release from the stomach.

Finally, a weak LES muscle can allow heartburn. If the muscle is unable to open and close completely, acid can sneak up into the esophagus. The LES muscle can be affected by:

• weight gain
  
• eating fatty foods
  
• drinking carbonated beverages
  
• drinking beverages high in caffeine
  
• drinking alcohol.
  

Medications that can reduce LES muscle strength

• nicotine
  
• beta blockers
  
• anticholinergics
• tricyclic antidepressants
  
• calcium channel blockers
  
• alcohol
• theophylline

Preventing heartburn

Avoiding triggers and implementing lifestyle changes may help prevent heartburn.

• Eat smaller, more frequent meals.
  
• Limit your trigger foods.
  
• Avoid lying down immediately following a meal.
  
• Maintain a healthy body weight.
  
• Do not eat within three hours before going to bed.
  
• Elevate the head of your bed by about six inches.
  
• Avoid tight and restrictive clothing.

Medication may help

Unfortunately, lifestyle changes are not always enough. Over-the-counter medications such as antacids may help combat discomfort. There are many different medications available so the choice can be overwhelming.

Antacids are commonly tried. Not all antacids are the same and they do not provide the same benefit for everyone. Four main ingredients make up antacids. Those available from your pharmacy will likely contain one or more of the following ingredients: sodium bicarbonate, aluminum, magnesium, or calcium. Each ingredient has advantages and disadvantages.

Many products combine aluminum and magnesium, which can work to balance the possible side effects of constipation and diarrhea. No matter which antacid you choose, keep in mind that not all over-the-counter medications are harmless.
Antacids can react with many medications. They provide relief by neutralizing acid in the stomach. As the strength in stomach acid changes, the body’s ability to activate or absorb some medications can be affected. Ingredients in antacids can also bind to certain medications, making those medications less effective. Some prescriptions warn that antacids must be taken two or three hours apart from other medications.

Other options

In addition to antacids, products may contain other ingredients that work in different ways to help provide relief.

Alginic acid is available in liquid and chewable form. Once chewed or swallowed, it combines with saliva and sodium bicarbonate to form a floating layer called sodium alginate. This layer acts like a barrier on top of the stomach acid. If stomach acid refluxes back into the esophagus, the floating layer can decrease acid contact with the tissue of the esophagus. Alginic acid is found in products such as Gaviscon Max Relief™ and Maalox Nighttime™ liquid.

Ranitidine (Zantac™) and famotidine (Pepcid™) belong to a class of medications known as histamine-2 blockers. They work by blocking the body’s signal to release acid in the stomach. These medications are often more effective when treating mild to moderate cases of heartburn.

Ranitidine is available over-the-counter in doses of 75 mg and 150 mg. In Canada, ranitidine 150 mg was only available by prescription. As of this year, it became available over-the-counter in limited pack sizes. Ranitidine begins working in about an hour and can provide relief for up to 12 hours.

Famotidine is also available over-the-counter in Canada, in 10 mg and 20 mg strengths. For symptoms of GERD, two doses a day are recommended. Higher doses, available by prescription only, may be needed if damaged tissue needs to be healed. Famotidine can be taken 15 to 60 minutes prior to a trigger meal. It will take action within one to three hours, and can provide relief for up to 12 hours.

Proton pump inhibitors, or PPIs, are another family of medications. They are used for moderate to severe heartburn and chronic symptoms of GERD. They include Nexium™ (esomeprazole), Pariet™ (rabeprazole), Pantoloc™ (pantoprazole), Losec™ (omeprazole), and Prevacid™ (lansoprazole). These medications significantly lower the amount of acid produced by blocking the acid pump. Reducing stomach acid can relieve reflux and heartburn.

The PPIs also help to heal damaged tissue or ulcers. Acid suppression can last up to 24 hours, so these medications are usually taken only once a day. Currently in Canada, they all require a written prescription from a doctor.

Red flag symptoms

Reducing pain and discomfort can control heartburn. However, preventing complications and healing existing damage is very important. Some people who experience heartburn may actually have damaged tissue in the stomach or esophagus. See a doctor if you experience any of the following warning symptoms:

• bleeding along with heartburn
  
• difficulty or pain with swallowing
  
• persistent vomiting
  
• experiencing heartburn for the first time at over 50 years of age
  
• pain and discomfort in the abdomen
  
• frequent heartburn while on anti-inflammatory medication.

Treating heartburn can improve quality of life for many people. Making lifestyle changes or using over-the-counter medications may bring relief. Antacids and other over-the-counter heartburn medications are only meant to provide temporary relief of minor acid reflux symptoms. Choose a product that will work best for your symptoms. Your pharmacist can help.

If you suffer from chronic heartburn or experience any red flag symptoms, consult your family doctor.