Heartburn medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Elsaiey, MBBCH [2] José Eduardo Riceto Loyola Junior, M.D.[3]

The treatment of heartburn in the setting of GERD is lifestyle modifications which include weight loss, elevating head of the bed and no eating before going sleep. The pharmacologic medical therapy is recommended among patients with persistent GERD despite following the lifestyle modifications. Antacids, histamine receptor antagonists, proton pump inhibitors, and prokinetics medications are used in treatment of GERD.

• The following measures are recommended as the first line to treat GERD:^[1][2][3][4]
  • Weight loss
  • Elevating head of the bed
  • No eating two hours before going sleep
• Avoidance of the following foods and lifestyles is recommended in treatment of GERD:
  • Coffee
  • Alcohol
  • Excessive amounts of Vitamin C supplements
  • Foods high in fats
  • Smoking
  • Eating shortly before bedtime
  • Large meals
  • Chocolate and peppermint.
  • Acidic foods, such as oranges and tomatoes.
  • Cruciferous vegetables such as: Onions, cabbage, cauliflower, broccoli, spinach, brussel sprouts
  • Milk and milk-based products

• The medical therapy is indicated for the patients who have persistent GERD regardless the lifystyle and food modifications.^[5][6]
• The following medical therapies are strongly recommended by the American College of Gastroenterology:
  • Antacids Antacids work by neutralizing excess stomach acid. Antacids provide fast relief of symptoms, but relief typically lasts for just 30-60 minutes. There may be rebound pain after its effect is over:
    • Preferred regimen (1): Aluminum hydroxide 640 mg 5 to 6 times daily PO after meals and at bed time.
    • Preferred regimen (2): Calcium carbonate One gram PO.
  • Histamine-receptor antagonists (H2RA) H2-receptor antagonists work by inhibiting the H2 receptor on parietal cells which signals the production of gastric acid by them:
    • Preferred regimen (1): Ranitidine 150 mg q12 daily PO
    • Preferred regimen (2): Cimetidine 400 mg q6h or 800 mg q12 PO for 12 weeks
    • Preferred regimen (3): Famotidine 20 mg q12 PO for 6 weeks
  • Proton pump inhibitors Proton pump inhibitors inhibit the proton (H+) pump localized at the apical part of the parietal cell and is responsible for acid secretion. These are the most potent gastric acid release inhibitors:
    • Preferred regimen (1): Omeprazole 20 mg q24 PO for up to 4 weeks
    • Preferred regimen (2): Esomeprazole 20 mg or 40 mg q24 IV
  • Prokinetic medications these medications work by stimulating proper contraction of the stomach and esophagus to make the gastric emptying happen faster, which decreases the likelihood of reflux of gastric content into the esophagus:
    • Preferred regimen (1): Metoclopramide 10 mg q24 PO for 4 to 12 weeks

• For chest pain in the setting of a proven acute coronary syndrome, the use of nitrates may improve it.
• In case of scleroderma the treatment for heartburn is the same as for GERD.
• For other causes such as eosinophillic esophagitis – treatment include specific dietary changes and proton pump inhibitors, with corticosteroids being used in a few cases.