Wednesday, October 28, 2020

Jennifer Mittler-Lee's COLUMN

A Definitive Guide to Heartburn and Alleviating the Symptoms

From Tums to Prilosec…your answers here

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We’ve all felt it at some point.

A burning sensation that starts in the chest and expands. Or maybe it’s a clenched fist in the stomach or a mysterious lump that cannot be swallowed. Perhaps it’s an unusual urge to cough.

Though the symptoms may vary, the cause is the same.

No shortage of stomach acid

Acid reflux, gastroesophageal reflux disease (GERD), sour stomach, or heartburn. They all describe the same condition: gastric acid hypersecretion, or too much stomach acid.

Overproduction of stomach acid can lead to a host of problems. An ulcer can occur when acid destroys the stomach’s protective layer of mucus. This leaves the inner lining vulnerable to damage. Ulcers may also form in the small intestine.

Ulcers can also be caused by a bacterial infection of H. pylori. In this case, medical intervention is essential as H. pylori can only be treated with a course of antibiotics.

GERD is the word

Gastroesophageal reflux disease (GERD) is what gives us those classic heartburn symptoms.

When gastric acid flows the wrong way back up into the esophagus, it is called reflux. Normally a gateway, called the esophageal sphincter, prevents this backflow. However, multiple factors can cause the esophageal sphincter to relax, allowing acidic contents in the stomach to escape.

These include:

  • Increased age
  • Pregnancy
  • Smoking
  • Medications like NSAIDs, heart medications, and anti-anxiety medications
  • Diet
  • Certain types of hernia
  • Obesity

The result is pain, burning, discomfort, and if left untreated, inflammation, and eventual build-up of scar tissue. Scarring can cause the tube-like esophagus to narrow, making it difficult to swallow food. This is known as esophageal stricture, and treatment may require surgical placement of a stent.

These long term complications are why it is imperative not to let chronic heartburn go untreated.

Mandatory Disclaimer

Before undertaking any self-treatment with over-the-counter medications, have a discussion with a doctor or pharmacist. Occasionally the symptoms of heartburn can be similar to a more serious cardiac issue. This is especially true for women, who may not always display the classic signs of a heart attack.

Lifestyle modifications- unsexy advice

As a pharmacist, my first recommendation is non-pharmacological intervention. No one wants to hear it, but losing weight and quitting smoking will help. So will resisting the urge to sleep on the couch after a heavy meal. Avoiding trigger foods is also sage advice.

For me, heartburn started in my 30s. Eating fried foods would trigger my symptoms without fail. While fatty foods are a common no-no, others include:

  • Protein-rich meals
  • Spicy foods
  • Alcohol
  • Chocolate
  • Acidic foods like citrus, grapes, pineapples, and tomatoes
  • Peppermint
  • Caffeine

I know. All the things that make life worth living.

Remember, not all of these foods will be triggers for everyone. My advice is to try an elimination diet. Take away foods that are believed to cause the pain and add them back one at a time. Soon you will have your culprit.

Stress is another cause. So many of our physical problems stem from mental ones.

I would always feel heartburn take hold after I had been at work for about an hour. I could go on about relaxation techniques — taking deep, cleansing breaths, and allowing for frequent breaks. But honestly, the only thing that helped me was not eating before going in to work.

Image for post
Berardi R, McDermott J, et al. Handbook of Nonprescription Drugs. 14th ed. Washington, DC: American Pharmacists Association; 2004:335–359.

So you’ve tried all these tips and still have heartburn? Then it’s time for a chat with your doctor or pharmacist.

Antacids

For mild, occasional heartburn, the first-line treatment consists of antacids. Maalox, Mylanta, and Tums are all examples.

Maalox and Mylanta are twins; a combination of aluminum and magnesium that works quickly to neutralize the acid in the stomach. Additionally, these thick liquids coat the stomach walls, providing a temporary protective layer.

Tums, a chewable tablet, contains calcium carbonate, another fast-acting acid neutralizer.

Antacids are all similar in efficacy. Let such factors as liquid versus chewable or price be your guide.

You may see a product called simethicone added to antacids. This agent reduces gas. It will not directly help manage heartburn symptoms. However, if you feel bloated or experience lower abdominal pain, simethicone could be useful.

Aside from icky taste, there are no major side effects for antacids.

It is a good idea to space antacids apart from other medications by at least 2 hours. The compounds in them can bind with other drugs, making them difficult for the body to absorb. This is especially important with antibiotics and medicine used to treat thyroid conditions and bone loss.

Use caution in individuals with kidney disease as the buildup of magnesium, aluminum, and calcium in the body is a potential problem.

Remember, antacids are only for short term use — 1 to 2 weeks. If they are not helping, consider adding or switching to an H2 blocker.

H2 Receptor Blockers

Also known as H2 receptor antagonists, these medications are a good choice for heartburn as they help to treat the cause. Although their onset of action is slower than antacids, about 1 hour, their duration lasts longer.

H2s work by blocking histamine receptors in the stomach. This blocking, or antagonism, prevents the signal that leads to the production of gastric acid.

Four brands are currently available over-the-counter (OTC):

  • Axid (nizatidine)
  • Zantac (ranitidine)
  • Pepcid (famotidine)
  • Tagamet (cimetidine)

I feel most comfortable recommending Pepcid due to its long history of use and the near absence of drug interactions.

Tagamet, as the first on the market, has the most adverse effects. Tagamet also affects liver enzymes more than the others and therefore displays more serious drug-drug interactions.

Zantac, normally a great choice,has been temporarily recalled for NDMA contamination — a possible carcinogen.

Axid was the last player to enter the H2 blocker arena, and as such, never gained as much popularity.

Side effects of H2 blockers are mild and include headache, nausea, and vomiting.

They are generally well-tolerated, but individuals with poor kidney function should avoid using H2 blockers long term. When used sparingly, the dose should be cut in half.

Limit self-treatment with H2 blockers to no more than 2 weeks without consulting a doctor. This is especially important as longer treatment appears to result in tolerance to the drugs with a resulting decreased efficacy.

Proton Pump Inhibitors

Proton pump inhibitors (PPIs) are gaining in popularity since a few made the switch from prescription (RX) to OTC a few years ago.

This class of drug displays the most benefit in reducing damage caused by the overproduction of acid. PPIs work by shutting down the pumps that produce gastric acid, giving the stomach a chance to heal.

The success of Prilosec (omeprazole) launched a series of competing “me too” drugs.

Other PPIs that made the RX to OTC switch include Nexium (esomeprazole) and Prevacid (lansoprazole).

In general, there are no practical differences between these three drugs. Honestly, pick whichever one appeals to the pocketbook.

Expect that PPIs will take a few days to start working. It may be beneficial to continue using antacids or H2 blockers until the full effects are felt.

PPI media hype: sifting truth from fiction

There have been many media reports about the dangers of PPIs. Many of these are unwarranted as this class of drugs is generally recognized as safe. Realistically, the most common side effects are headache, rash, and diarrhea.

However, when used long-term, PPIs do come with a few caveats.

Certain populations using PPIs, like the elderly or immunocompromised, appear to have an increased risk of infection. Clostridium difficile, a particularly nasty bug that causes severe diarrhea, and pneumonia are of greatest concern.

The theory is the acidic environment in our stomach normally suppresses bacterial overgrowth. If we neutralize this defense, bacteria can flourish.

Incidentally, there may be a correlation between PPI use and coronavirus. Early data suggests a link between low amounts of stomach acid and the proliferation of the coronavirus — leading to more positive tests. However, further research is needed.

Increasing the pH of the stomach may also lead to absorption problems. Calcium, magnesium, and vitamin B-12 are a few of the affected essential vitamins and minerals. Low calcium is of special concern to an elderly population already at increased risk of bone loss, or osteoporosis.

Consider talking to your doctor or pharmacist about supplementation.

It is also recommended not to abruptly quit PPI use after long-term therapy. Slowly tapering off the drug avoids the rebound effect of increased acid production.

Drug interactions with PPIs mainly result because of competition for the liver enzymes that aid in metabolism. However, they can also be a result of the increased pH in the stomach. Many drugs need an acidic environment to be activated.

Major interactions between PPIs exist with:

  • Antiretrovirals (HIV medications)
  • Anti-fungals
  • Anti-depressants
  • Chemotherapy agents
  • Anti-seizure medications
  • Plavix (clopidogrel) — an important antiplatelet drug used to prevent heart attack or stroke

Because of the potential for serious long term effects and severe drug interactions, I recommend talking to your doctor first before initiating PPI self-therapy.

Heartburn in pregnancy

Heartburn is a common complication in pregnancy, with the majority of symptoms occurring in the last trimester.

Studies evaluating a drug’s safety profile in human pregnancies are scarce. Usually, we rely on animal studies when making recommendations. Plus, the benefits to risk ratio must be considered.

The safest solutions for pregnant women with heartburn are the lifestyle modifications discussed earlier. Eat smaller, more frequent meals, avoid trigger foods, and elevate the head of the bed with pillows to avoid lying flat. Chewing gum to release saliva may also help promote digestion.

Consider occasional treatment of heartburn in pregnancy with a calcium-containing antacid like Tums first. Magnesium also seems to be safe in low doses. However, a few studies have agreed that limiting the amount of aluminum may be prudent.

H2 blockers have also been safely used, but it is recommended to be under a doctor’s guidance. Although they appear safe in the first trimester, PPIs should only be used under doctor supervision.

Summary

Although it seems a minor inconvenience, heartburn can lead to more serious problems. It should never be ignored.

Avoid or limit those trigger foods, and make appropriate lifestyle changes when possible.

Consider treating the occasional mild case of heartburn with an antacid. Add an H2 blocker, like Pepcid, if no relief.

If no comfort is felt from either agent, it is reasonable to consult with a doctor or pharmacist before starting a PPI. Although they work best, they also have the most potential long term effects and drug interactions. Also, a checkup can help rule out other causes.

Never ignore warning signs of a more serious condition such as:

  • Blood in the stool
  • Unexplained weight loss
  • Food getting stuck in the throat

With a few changes, heartburn does not have to be a daily event. That fire in the stomach can be extinguished.

Patient Advisory

Medika Life has provided this material for your information. It is not intended to substitute for the medical expertise and advice of your health care provider(s). We encourage you to discuss any decisions about treatment or care with your health care provider. The mention of any product, service, or therapy is not an endorsement by Medika Life

Jennifer Mittler-Lee B.S. Pharmahttps://medium.com/@jrmittle

I am a pharmacist with over 20 years in the industry. I have worked both retail and hospital and have been known to frequent the nightshift. As a pharmacist, I see how medical jargon confuses people. I like to write healthcare articles in a casual manner in order to connect. Find me on Medium @jrmittle

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Jennifer Mittler-Lee's Column

I am a pharmacist with over 20 years in the industry. I have worked both retail and hospital and have been known to frequent the night shift. As a pharmacist, I see how medical jargon confuses people. I like to write healthcare articles in a casual manner in order to connect.

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