Over-the-Counter and Prescription Medications for GERD

Over-the-counter or prescription medications may be the most appropriate next step for the treatment of GERD if diet and lifestyle changes do not relieve symptoms. For many patients, treatment with medicines will reduce heartburn and reflux symptoms. Patients with more severe symptoms may only experience partial symptom control through medicines.

Acid suppression is the main function of GERD medical therapy. Three types of medications are commonly used to treat GERD:

  • Antacids
  • H2-receptors (H2RAs)
  • Proton pump inhibitors (PPIs) – the most commonly used medication to treat GERD symptoms and to heal esophagitis

Types of Medications

  • Antacids: This type of medication directly neutralizes gastric acid and provides rapid but temporary relief. Antacids are usually consumed in frequent doses as needed, and most are available over the counter.
  • H2RAs: H2RAs reduce the amount of acid produced in the stomach by inhibiting the release of histamine, the principal stimulus for acid secretion in the stomach. Clinical trials evaluating histamine for the treatment of GERD showed only modest benefit over a placebo. Also, several studies have revealed drug tolerance to H2RAs as early as two weeks after beginning therapy. [1] This means that patients experience a reduced reaction to a given dosage relatively quickly after starting to use it.
  • PPIs: PPIs are the most effective medical therapy to treat GERD . PPIs work by blocking the mechanism that produces stomach acid. This lowers the acidity of the digestive fluids involved in reflux, and thus reduces reflux symptoms. PPIs are available in both prescription and over-the-counter strengths.

While effective at reducing the acidity of digestive fluids in the upper GI tract, PPIs do not address anatomic deficiencies which often are the root cause of abnormal reflux. [2]

Long-Term PPI Use

PPIs are generally approved by the FDA for eight weeks of use for the healing of esophagitis, and they are safe and effective for most patients. However, studies evaluating PPI use over an extended period of time demonstrate several potential long-term concerns including:

  • Vitamin B12 deficiency [3]
  • Increased pneumonia risk [4]
  • Increased risk of osteoporosis fractures [5]
  • Reduced gall bladder motility [6]
  • PPI interaction with Plavix [7]
  • Increased risk of stomach polyps [8]
  • Increased risk of bacterial gastroenteritis [9]
  • Magnesium deficiency [10]
  • Increased risk of small intestine bacterial infection [11]
  • Chronic kidney disease [12]
  • Dementia [13]

See the FDA Proton Pump Inhibitor Safety page for details on long-term side-effects of PPI use.

Limitations of Medicines for Treating GERD

Medication can help control symptoms such as heartburn by reducing the acidity of reflux, but it does not change the amount or quantity of reflux. As a result, it can leave other symptoms such as difficulty swallowing, frequent regurgitation, or chronic respiratory problems unresolved.

If the medication regimen is stopped, reflux-related symptoms typically recur. This can lead to dependence on these medicines. Over time, the medication can lose its effectiveness, requiring higher doses or more powerful medicines.

Having reflux from time to time is normal; having it interrupt your life is not. If you suffer symptoms of reflux twice or more per week, you may have GERD. Take this GERD survey if you suspect a problem.

References:

[1] Sontag SJ. The medical management of reflux esophagitis. Role of antacids and acid inhibition. Gastroenterol Clin North Am 1990; 19(3): 638-712.
[2] Chiba N. Proton pump inhibitors in acute healing and maintenance of erosive or worse esophagitis: a systematic overview. Can J Gastroenterol 1997; 11(suppl B):66B–73B.
[3] Dharmarajan TS, et al. Do Acid-Lowering Agents Affect Vitamin B12 Status in Older Adults. JAMDA 2008; 9: 162-167.
[4] Eom CS, et al. Use of acid-suppressive drugs and risk of pneumonia: systematic review and meta-analysis. CMAJ 2010.
[5] Targownik LE, et al. Use of proton pump inhibitors and risk of osteoporosis-related fractures. CMAJ 2008; 179(4): 319-26.
[6] Cahan MA, et al. Proton pump inhibitors reduce gallbladder function. Surg Endosc 2006; 20: 1364-1367.
[7] Ho, PM, et. al., JAMA 2009 Mar 4;301(9):937-44.
[8] Jalving, M, et. al., Aliment Pharmacol Ther. 2006 Nov 1;24(9):1341-8.
[9] Rodriguez L, et al. Use of Acid Suppressing Drugs and the Risk of Bacterial Gastroenteritis. Clin Gastroenterology and Hepatology 2007; 5: 1418-1423.
[10] Cundy T and Dissanayake A. Severe hypomagnesaemia in long-term users of proton-pump inhibitors. Clinical Endocrinology 2008; 69: 338-341.
[11] Lombardo L, et al. Increased Incidence of Small Intestinal Bacterial Overgrowth During Proton Pump Inhibitor Therapy. Clin Gastroenterology and Hepatology 2010; 8:504-508.
[12] Lazarus B, et. al., JAMA Intern Med. 2016 Feb 1;176(2):238-46.
[13] Gomm W et. al., JAMA Neurol. 2016 Feb 15. doi: 10.1001/jamaneurol.2015.4791.