Heartburn Prevention

John Horn, PharmD, is a professor of pharmacy at the University of Washington School of Pharmacy. Below, he discusses different methods of heartburn treatments, and the benefits and limitations of each.

What do we mean when we complain of heartburn?
When people complain of heartburn, they're usually talking about a burning sensation that starts low in the chest and rises up beneath the sternum, sort of centrally located in the chest, and often it feels like it's an ascending, burning feeling.

Gastroesophageal reflux disease (GERD) is essentially heartburn and a number of other symptoms that are put together and labeled with the name GERD to describe it as a disease. It's often a diagnosis that's made by a physician, either after a careful physical examination and perhaps some invasive testing, and also based on the symptoms that a patient has.

What causes heartburn?
It is almost always caused by acid from the stomach irritating the esophagus and causing pain. Some people don't have very good muscle control in the sphincter that's at the bottom of the esophagus, which prevents stomach contents from coming back into the esophagus. And when that muscle doesn't work very well, sometimes they get reflux of stomach contents into their esophagus.

How prevalent is heartburn in America?
I think the number of Americans that have heartburn is really very large, and we're probably talking about 20 or 30 million adult Americans. So it's a common problem. The majority of patients with heartburn have episodic, reasonably easy-to-control heartburn.

Can heartburn be prevented?
The goal of heartburn treatment is really symptom relief. It's either complete or partial relief of symptoms to enable the patient to better function and enjoy life without the recurrence of heartburn.

Most heartburn is amenable to prevention therapy. Certainly, people who have episodic heartburn, that's perhaps triggered by certain meals or certain kinds of foods is really treatable by prevention therapy. There's a number of different ways that you can do that. But I think prevention therapy is a useful idea for almost everyone with heartburn.

How can people prevent heartburn?
There are a number of lifestyle approaches that have been suggested for people with heartburn, and they include such things as not eating meals before you go to bed. You should probably stop eating two or three hours before going to bed. Eating smaller meals. Avoiding foods that maybe are spicy or have a high acid content, like tomatoes or fruit juices. Those have all been associated with increasing heartburn.

If people are a little on the heavy side, they should try and lose weight. People can elevate the head of the bed a bit so that when they sleep at night there's more of a slope on their esophagus to keep the stomach contents down in the stomach. So there actually are a number of things that can be tried.

What are some medications for heartburn prevention?
There are a number of different medicines that you can use to prevent heartburn. Some of them are available over-the-counter. And then there also are medicines that are only available by prescription.

There are probably three major categories of drugs that are used to prevent heartburn. The first would be antacids, which are all available over-the-counter. Secondly, there are a group of drugs called the H2 blockers. All of those are available over-the-counter. And the third class is a class called proton pump inhibitors. One drug out of that class is now available over-the-counter (OTC), and then there are other drugs in that class, which are only available by prescription.

How effective are over-the-counter medicines?
I think a lot of patients get good relief from over-the-counter medicines. They may find that they may have to try different medicines or combinations or different doses or combine them with some lifestyle changes, but if a patient works at it, they can usually get pretty good relief from a simple episodic heartburn.

OTC medications are a great idea for prevention, because, after all, this is a condition, which is episodic. Sometimes people have symptoms and sometimes they don't. So using an episodic treatment for an episodic disease seems to make good sense.

Can antacids prevent heartburn?
Antacids are a group of drugs that neutralize stomach acid, and so they treat heartburn by neutralizing the acid that's come up into the esophagus and in the stomach. They generally would not be effective at preventing heartburn because their duration of action is too short. When you take an antacid you can treat the episode of heartburn that you're having right now, but it's not going to do much to prevent an episode happening later in the day or tomorrow. So they're really intended for acute treatment of heartburn. Acid blockers really are indicated for the prevention of heartburn.

How do H2 blockers work?
There's a cell in the stomach called a parietal cell, and that parietal cell makes acid. There are a number of different things that stimulate that cell, and one of them is histamine. H2 blockers simply block prevent histamine from stimulating the parietal cell, thus reducing the amount of acid that's made. H2 blockers are quite effective at preventing heartburn attacks, and they're also pretty useful for treating other conditions such as ulcers or esophagitis that are the result of excess acid.

H2 blockers are most effective at preventing episodes of heartburn. So if a patient, for example, is planning to go out to dinner and have a large meal, and perhaps a meal with some spicy food that the patient knows might produce some heartburn, by taking the H2 blocker an hour or two before the meal, they can reduce the amount of acid that's produced by the stomach in response to that meal, and therefore reduce the likelihood that they'll actually get a heartburn attack.

Do H2 blockers have limitations?
The main limitation of H2 blockers is that their duration of action is probably eight or ten or twelve hours, so that if you take an H2 blocker in the morning and then go out and have dinner, it may not offer protection. They really need to be taken within an hour or two of the meal that you think is going to cause the problem. So I think probably the major limitation for those drugs is that their duration of action is just part of a day, not a whole day.

If somebody forgets to take their H2 before a meal and they remember either during the meal or right afterwards. In that interim period, however, if the person develops heartburn, they could take an antacid. They could take a separate antacid, or they could take an H2 product that already has an antacid built in with it as a single product, and that would give them the protection of the antacid and then the protection of the H2.

How do proton pump inhibitors (PPIs) work?
Parietal cells in the stomach secrete acid, and the part of the parietal cell that does that is called the proton pump. Proton pump inhibitors bind to that proton pump and prevent it from secreting the acid out of the parietal cell and into the stomach.

The difference between the way a proton pump inhibitor works and an H2 blocker is that the proton pump inhibitor is working at the site where the acid is being made and the H2 blocker is working at a site which stimulates the parietal cell. And because of that, the proton pump inhibitors generally have a more potent effect on suppressing acid secretion by the parietal cell than does the H2 blocker.

A proton pump inhibitor might be effective in those people who have they had tried an H2 blocker but had not gotten complete relief. In other words, they were still having symptoms while taking their H2 blocker and need something a little more potent to suppress enough acid to eliminate their symptoms.

Do PPIs have limitations?
The onset of effectiveness varies a bit with each PPI. Generally, we're talking about at least a day, and with the over-the-counter PPI, we may be talking about more like two or three days to really become effective.