
Get answers to your GERD/LERD questions.
Dr. Fantry’s Bio | Q&A Archive
Heartburn; GERD
Antacids neutralize acids in the stomach, and are the drugs of choice for mild GERD symptoms. They may also stimulate the defensive systems in the stomach by increasing bicarbonate and mucus secretion. They are best used alone for relief of occasional and unpredictable episodes of heartburn. Many antacids are available without a prescription. The different brands all rely on various combinations of three basic ingredients: magnesium, calcium, or aluminum.
Magnesium. Magnesium salts are available in the form of magnesium carbonate, magnesium trisilicate, and most commonly, magnesium hydroxide (Milk of Magnesia). The major side effect of magnesium salts is diarrhea. Magnesium salts offered in combination products with aluminum (Mylanta and Maalox) balance the side effects of diarrhea and constipation.
Calcium. Calcium carbonate (Tums, Titralac, and Alka-2) is a potent and rapid-acting antacid. It can cause constipation. There have been rare cases of elevated levels of calcium in the blood (hypercalcemia) in people taking large doses of calcium carbonate for long periods of time. This condition can lead to kidney failure and is very dangerous. None of the other antacids has this potential side effect.
Aluminum. Aluminum salts (Amphogel, Alternagel) are also available. The most common side effect of antacids containing aluminum salts is constipation. People who take large amounts of antacids that contain aluminum may also be at risk for calcium loss, which can lead to osteoporosis.

Although all antacids work equally well, it is generally believed that liquid antacids work faster and are more potent than tablets. Antacids can interact with a number of drugs in the intestines by reducing their absorption. These drugs include tetracycline, ciprofloxacin (Cipro), propranolol (Inderal), captopril (Capoten), and H2 blockers. Interactions can be avoided by taking the drugs 1 hour before, or 3 hours after taking the antacid. Long-term use of nearly any antacid increases the risk for kidney stones.
Proton pump inhibitors (PPIs) suppress the production of stomach acid and work by inhibiting the molecule in the stomach glands that is responsible for acid secretion (the gastric acid pump). Recent guidelines indicate that PPIs should be the first drug treatment, because they are more effective than H2 blockers. Once symptoms are controlled, patients should receive the lowest effective dose of PPIs.
The standard PPI has been omeprazole (Prilosec), which is now available over the counter without a prescription. Newer prescription oral PPIs include esomeprazole (Nexium), lansoprazole (Prevacid), rabeprazole (AcipHex), and pantoprazole (Protonix). In February 2009, the FDA approved the long-acting PPI dexlansoprazole (Kapidex), which is taken once a day.
Studies report significant heartburn relief in most patients taking PPIs. PPIs are effective for healing erosive esophagitis and may also be helpful in patients with chronic laryngitis that is suspected to be caused by GERD.
In addition to relieving most common symptoms, including heartburn, proton pump inhibitors also have the following advantages:
Patients with impaired esophageal muscle action are still likely to have acid breakthrough and reflux, especially at night. PPIs also may have little or no effect on regurgitation or asthma symptoms.
Currently, these drugs are recommended for patients with:
These medications have no effect on non-acid reflux, such as bile backup.
Adverse Effects. Proton-pump inhibitors may pose the following risks:
Some evidence suggests that acid reflux may contribute to the higher risk of cancer in Barrett's esophagus, but it is not yet confirmed whether acid blockers have any protective effects against cancer in these patients. Moreover, long-term use of proton pump inhibitors by people with H. pylori may reduce acid secretion enough to cause atrophic gastritis (chronic inflammation of the stomach). This condition is a risk factor for stomach cancer. To compound concerns, long-term use of PPIs may mask symptoms of stomach cancer and thus delay diagnosis. To date, however, there have been no reports of an increased risk of stomach cancer with the long-term use of these drugs.
There had been concerns that the PPIs Prilosec and Nexium might lead to heart attacks or cardiovascular problems. However, after a careful review, the FDA found no evidence of increased cardiovascular risk.
H2 blockers interfere with acid production by blocking or antagonizing the actions of histamine, a chemical found in the body. Histamine encourages acid secretion in the stomach. H2 blockers are available over the counter and relieve symptoms in about half of GERD patients. It takes 30 - 90 minutes for them to work, but the benefits last for hours. People usually take the drugs at bedtime. Some people may need to take them twice a day.
H2 blockers inhibit acid secretion for 6 - 24 hours and are very useful for people who need persistent acid suppression. They may also prevent heartburn episodes. In some studies, H2 blockers improved asthma symptoms in people with both asthma and GERD. However, one study suggested that they rarely provide complete symptom relief for chronic heartburn and dyspepsia, and they have done little to reduce physician office visits for GERD.
Brands. Four H2 blockers are available in the U.S.:
Drug Combinations.
Long-Term Complications. In most cases, these medications have good safety profiles and few side effects. H2 blockers can interact with other drugs, although some less so than others. In all cases, the physician should be made aware of any other drugs a patient is taking. Anyone with kidney problems should use famotidine only under a doctor's direction. More research is needed into the effects of long-term use of these medications.
Concerns and Limitations. Some experts are concerned that the use of acid-blocking drugs in people with peptic ulcers may mask ulcer symptoms and increase the risk for serious complications.
These drugs do not protect against Barrett's esophagus. Also of concern are reports that long-term acid suppression with these drugs may cause cancerous changes in the stomach in patients who are infected with H. pylori. Research on this question is still ongoing.
Famotidine is removed primarily by the kidney. This can pose a danger to people with kidney problems. The FDA and Health Canada are advising physicians to reduce the dose and increase the time between doses in patients with kidney failure. Use of the drug in those with impaired kidney function can affect the central nervous system and may result in anxiety, depression, insomnia or drowsiness, and mental disturbances.
Sucralfate (Carafate) protects the mucus lining in the gastrointestinal tract. It seems to work by sticking to an ulcer crater and protecting it from the damaging effects of stomach acid and pepsin. Sucralfate may be helpful for maintenance therapy in people with mild-to-moderate GERD. Other than constipation, the drug has few side effects. Sucralfate interacts with a wide variety of drugs, however, including warfarin, phenytoin, and tetracycline.
Most drugs used for GERD have no effect on non-acid reflux, such as the backup of bile. Baclofen is commonly used to reduce muscle spasms. Studies are now showing that it can reduce both acid and non-acid reflux episodes and increase LES pressure, an important factor for preventing acid backup.
Brant K. Oelschlager BK, Eubanks TR, Pellegrini CA. Hiatal Hernia and Gastroesophageal Reflux Disease. In: Townsend: Sabiston Textbook of Surgery, 18th ed. Philadelphia, PA:WB Saunders; 2007:chap 42.
Chang EY, Morris CD, Seltman AK, et al. The effect of antireflux surgery on esophageal carcinogenesis in patients with barrett esophagus: a systematic review. Ann Surg. 2007;246(1):11-21.
Friedenberg FK, Xanthopoulos M, Foster GD, Richter JE. The association between gastroesophageal reflux disease and obesity. Am J Gastroenterol. 2008;103:2111-2122.
Furnée EJ, Draaisma WA, Broeders IA, Smout AJ, Gooszen HG. Surgical reintervention after antireflux surgery for gastroesophageal reflux disease: a prospective cohort study in 130 patients. Arch Surg. 2008;143:267-274.
Gee DW, ANdreoli MT, Rattner DW. Measuring the effectiveness of laparoscopic antireflux surgery: long-term results. Arch Surg. 2008;143:482-487.
Herzig SJ, Howell MD, Ngo LH, Marcantonio ER. Acid-suppressive medication use and the risk for hospital-acquired pneumonia. JAMA. 2009;301:2120-2128.
Hirano I, Richter JE, and the Practice Parameters Committee of the American College of Gastroenterology. ACG practice guidelines: esophageal reflux testing. American Journal of Gastroenterology. 2007;102:668-685.
Islami F, Kamangar F. Helicobacter pylori and esophageal cancer risk: a meta-analysis. Cancer Prev Res. 2008;1:329-338.
Jeansonne LO, White BC, Nguyen V, Jafri SM, Swafford V, Katchooi M, et al. Endoluminal full-thickness plication and radiofrequency treatments for GERD: An outcomes comparison. Arch Surg. 2009;144:19-24.
Kahrilas PJ, Shaheen NJ, Vaezi MF, Hiltz SW, Black E, Modlin IM. American Gastroenterological Association Medical Position Statement on the management of gastroesophageal reflux disease. Gastroenterology. 2008;135:1383-1391.
Jacobson BC, Moy B, Colditz GA, et al. Postmenopausal Hormone Use and Symptoms of Gastroesophageal Reflux. Arch Intern Med. 2008;168(16):1798-1804.
Mishkin DS, Chuttani R, Croffie J, et al. ASGE Technology Status Evaluation Report: wireless capsule endoscopy. Gastrointestinal Endoscopy. 2008;63(4): 539-545.
Orenstein S, Peters J, Khan S, et al. Gastroesophageal Reflux Disease (GERD). In: Kliegman: Nelson Textbook of Pediatrics, 18th ed. Philadelphia, PA: WB Saunders; 2007:chap 320.
Rodriguez LG, Ruigómez A, Martin-Merino E, Johansson S, Wallander MA. Relationship between gastroesophageal reflux disease and COPD in UK primary care. Chest. 2008;1223-1230.
Talley NJ, Locke GR 3rd, McNally M, Schleck CD, Zinsmeister AR, Melton LJ 3rd. Impact of gastroesophageal reflux on survival in the community. Am J Gastroenterol. 2008;103:12-19.
Targownik LE, Lix LM, Metge CJ, Prior HJ, Leung S, Lesie WD. Use of proton pump inhibitors and risk of osteoporosis-related fractures. CMAJ. 2008;179:319-326.
Wang KK, Sampliner RE. Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett's esophagus. Am J Gastroenterol. 2008;103(3):788-97.
Wilson JF. In The Clinic: Gastroesophageal Reflux Disease. Ann Intern Med. 2008;149(3):ITC2-1-15.
Zhao Y, Encinosa W. Gastroesophageal Reflux Disease (GERD) Hospitalizations in 1998 and 2005. Agency for Healthcare Research and Quality, January 2008.