If you suffer from heartburn, the advertising for some products make them seem like a foolproof solution. Ads for Nexium 24HR claim the “purple pill” provides “complete protection from heartburn,” those for Prilosec OTC promise “zero heartburn", and Prevacid 24HR tempts you with delicious foods you can enjoy “heartburn free” if you take the drug.
Strong claims for what are, indeed, strong medicines. All of those products fall into a category of drugs called proton-pump inhibitors, or PPIs. And if you are plagued by frequent heartburn due to gastroesophageal reflux disease (GERD), which occurs when acid from your stomach repeatedly washes up into your esophagus, a PPI can provide relief.
But PPIs have drawbacks that make them a poor choice for most heartburn sufferers. In fact, up to 70 percent of people who take a PPI might not need such potent acid reducer and could get just as much—or more—relief from a safer heartburn remedy.
The Problem With PPIs
To begin with, PPIs don’t provide immediate relief for occasional heartburn says M. Michael Wolfe, M.D., chair of the department of medicine at Case Western Reserve University in Cleveland, Ohio. Unlike other heartburn remedies you find on the drugstore shelves, he says, PPIs are meant to be taken daily, and take several days to start working. “These drugs are intended to be taken regularly to prevent symptoms in people who have a serious, ongoing problem.”
The other problem with PPIs is that they may cause rare, but serious side effects, especially if you use them day after day for a year or longer. Because of those and other risks linked to long-term use, the American Gastroenterological Association recommends that people who need a PPI take the drug for the shortest time necessary to address symptoms.
But there’s a catch: Once you’ve been taking a PPI for weeks, months, or years, it can be hard to stop without suffering a rebound effect in which your stomach overproduces acid. Uncomfortable symptoms—such as a burning pain in your lower chest, nausea, and food coming up into your throat—tend to come roaring back.
“People can wind up on PPIs indefinitely—even if they don’t need them—because they start to suffer rebound symptoms every time they try to stop,” Wolfe says.
When to Consider a PPI—and When Not To
For fast relief from occasional heartburn—say, after a heavy meal—try an antacid such as Maalox, Mylanta, Rolaids, or Tums. Another option is an H2 blocker such Pepcid AC or Zantac 75, which won’t work quite as quickly, but can have a longer-lasting effect. Or you can find products such as Pepcid Complete that combine both types of medication in one pill. All of those products typically cause fewer side effects and are cheaper than PPIs. (You can save even more with generic store brands.)
If your heartburn persists despite those remedies and occurs frequently—twice weekly or more for weeks or months on end—don’t continue to try to treat yourself. Talk to your doctor to get to the bottom of what’s causing your symptoms. Frequent burning or pain in the upper abdomen or chest could signal a number of different conditions, including an ulcer, gallbladder disease, or even a heart attack.
If your doctor diagnoses GERD, you may indeed need a PPI. Left untreated, GERD can damage the lining of the esophagus, which can lead to serious complications such as ulcers and difficulty swallowing and even increases the risk of cancer of the esophagus. “For patients with GERD, the benefits of treatment clearly outweigh the risks,” says Wolfe.
Seven PPI drugs are currently available in the U.S. Four are sold both by prescription and over the counter: esomeprazole (Nexium, Nexium 24HR), lansoprazole (Prevacid, Prevacid 24HR), omeprazole (Prilosec, Prilosec OTC), and omeprazole/sodium bicarbonate (Zegerid, Zegerid OTC). Three others—dexlansoprazole (Dexilant), pantoprazole (Protonix), and rabeprazole (AcipHex)—are available only by prescription. (Many OTC and prescription products are also available in generic versions.)
If you do wind up needing a PPI drug, talk to your doctor about starting with an OTC product. Our Best Buy Drug report found that all PPIs were roughly equal in terms of their safety and how well they worked, and OTC products, especially generics, tend to be much cheaper than prescription versions.
Plan an Exit Strategy
How long you take a PPI depends on your condition and the severity of your symptoms says Wolfe. If your esophagus is damaged, for example, you'll need to take the acid-reducing medication for two to three months to give it time to heal. Once your symptoms have resolved, discuss a timeline with your doctor for weaning off the drugs.
You’ll need to taper off slowly to avoid rebound symptoms. There are no specific guidelines for stopping PPIs, so talk with your doctor to arrive at a strategy that makes sense for you. For example, you could first reduce your daily dosage, then cut back to every other day, and then every few days before finally stopping completely. If needed, you can take an H2 blocker to manage symptoms on days you don’t take the PPI.
Unfortunately, GERD symptoms tend to recur says Wolfe, so some people wind up needing to resume taking a PPI. “But you may be able to manage symptoms through other measures such as H2 blockers and lifestyle changes,” he says.
And don’t underestimate the role of diet and lifestyle, says Wolfe. Research clearly shows that obesity is a strong risk factor for GERD and shedding excess pounds “can make a huge difference” he says. Other strategies that can help: eating smaller meals; not lying down for at least 3 hours after eating; and avoiding trigger foods and drinks such as citrus fruit, garlic, onions, fried foods, caffeine, and alcoholic beverages.
Editor's Note: This article is made possible by a grant from the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by the multistate settlement of consumer-fraud claims regarding the marketing of the prescription drug Neurontin (gabapentin).
