Self Care Heartburn/ Dyspepsia

Antacids and histamine type 2 receptor antagonists (H2RAs) should be

recommended for

individuals with mild, infrequent heartburn and

dyspepsia

Antacids provide rapid relief of symptoms

1. Onset: less than 5 minutes

2. Duration: 20-30 minutes

H2RAs are preferred to an antacid when individuals with mild-

moderate heartburn require more prolonged relief of symptoms (1 time a week)

1. Onset: 30-45 minutes

2. Duration: 4-10 hours

3. Also used to prevent heartburn when given 30 minutes

to 1 hour prior to when heartburn is anticipated (only with H2 blocker)

3 Classes of heart burn medication

-antacids

-H2RAs

-Proton Pump Inhibitors (PPIs)

Combo product (Antacid + H2RA)

Quick relief is desired along with a longer duration of action

1. Onset: less than 5 minutes

2. Duration of Action: 8 to 10 hours

Proton Pump Inhibitors (PPIs) can be used for treating frequent

heartburn (2 or more days per week) or when patients do not respond to

H2RAs

i. Should be limited to duration of 14 days and retreatment to every 4 months (only OTC for 2 weeks)

1. Onset: 2-3 hours

2. Duration of Action: 12-24 hours (first time use may require

up to 4 days for complete relief of symptoms)

Antacids Pharmacologic Therapy

Neutralize gastric acid; act as buffering agents and increase LES

pressure

ii. Indicated for the treatment of mild, infrequent heartburn, sour

stomach, and acid indigestion; taken at the onset of symptoms

and dosing may be repeated in 1-2 hours, if needed

iii. Contain at least one of the following salts: magnesium (hydroxide,

carbonate), aluminum (hydroxide, phosphate), calcium carbonate,

and sodium bicarbonate

Antacids Magnesium containing

= dose related diarrhea

Aluminum containing antacids

= dose related constipation

Calcium containing antacids

= constipation reported

Sodium bicarbonate

= high sodium content may cause

fluid overload (CHF, renal failure, sodium restricted diets)

Antacids Alka-Seltzer® (sodium bicarbonate), Mylanta®

(magnesium + aluminum or calcium), Tums® (calcium carbonate),

Rolaids® (calcium + magnesium)

Inexpensive, affordable products for the temporary relief of mild-

moderate (infrequent) heartburn and dyspepsia

v. Liquid antacids have a faster onset

than tablets because they are already dissolved

vi. Duration of action lasts only as long as the antacid remains in the

stomach

vii. May potentially decrease the absorption of other medications;

separate drug doses by 2 hours (ex. iron, antibiotics, antifungals)

viii. Examples include: Alka-Seltzer® (sodium bicarbonate), Mylanta®

(magnesium + aluminum or calcium), Tums® (calcium carbonate),

Rolaids® (calcium + magnesium)

Histamine Type 2 Receptor Antagonists (H2RAs)

Decrease fasting and food-stimulated gastric acid secretion by

inhibiting histamine on the histamine type 2 receptor of the

parietal cell; therefore, relieve fasting and night-time symptoms

ii. Indicated for mild-moderate, infrequent, or episodic heartburn

and for the prevention of heartburn

associated with acid indigestion and sour stomach

H2RAs -stomach

Used at the onset of symptoms or 30 minutes to 1 hour prior to

an event (meal or exercise) in which heartburn is anticipated

iv. Onset is not as rapid as antacids, but duration of effect is longer

v. Tolerance to the gastric effects may develop when taken daily

versus as needed and may be responsible for diminished efficacy

1. Preferable to take PRN rather than daily

H2RAs amotidine (Pepcid® & Zantac®) and

Cimetidine (Tagamet®)

AVOID cimetidine (Tagamet): inhibits CYP450 enzymes,

several drug interactions, decreases libido, and causes impotence

and gynecomastia in men

vii. Examples include: Famotidine (Pepcid® & Zantac®) and

Cimetidine (Tagamet®)

Combination products include:

Pepcid Complete® and Tums Dual Action®:

famotidine, calcium carbonate, magnesium

hydroxide

Proton Pump Inhibitors (PPIs)

Decrease gastric acid secretion by inhibiting hydrogen potassium

ATPase (the proton pump), irreversibly blocking the final step in

gastric acid secretion

ii. Indicated for the treatment of frequent heartburn in patients who

have symptoms 2 or more days a week; NOT intended for relief of

mild, occasional heartburn (not as needed every day for 14 days)

PPIs Onset *

Onset may occur in 2-3 hours, but complete relief may take 1-4

days

iv. Only inhibit those proton pumps actively secreting acid, therefore

most effective when taken 30-60 min before meal,

preferably before breakfast

v. Self-treatment should be limited to 14 days

and no more frequently than every 4 months

PPIs Warnings

Chronic acid suppression has the potential to impair natural

defenses and to increase the risk of infection

1. Increased susceptibility to community acquired

pneumonia

2. Association with infections such as Clostridium difficile (C.

diff)

vii. Reduced gastric acid secretion may decrease calcium absorption

1. Increased risk for hip, spine, and wrist fractures in older

patients > 50 years

2. Risk is low with appropriate OTC use; associated more with

high-dose, long term (> 1 year) PPI therapy

3. Calcium citrate is the preferred

calcium supplement form for patients taking acid-reducing

medications such as PPIs, given that citrate salts do not

require an acid environment for dissolution

PPIs omeprazole (Prilosec®), lansoprazole

(Prevacid®), and esomeprazole (Nexium®)

Recent studies have shown potential risks with long term use of

PPIs associated with dementia and chronic kidney disease

1. PPIs recently added to the Beers Criteria for Potentially

Inappropriate Medication Use in Older Adults

ix. Examples include: omeprazole (Prilosec®), lansoprazole

(Prevacid®), and esomeprazole (Nexium®)

Dose for all OTC PPI products

1 capsule 30-60 minutes

before morning meal; take daily for 14 days—make sure to

take the full 14 day course treatment

Combination product includes:

omeprazole and sodium

bicarbonate (Zegerid®); claims sodium bicarbonate raises

pH permitting rapid absorption of omeprazole

Other agents

Bismuth Subsalicylate (BSS)/Pepto-Bismol® is indicated for

heartburn, upset stomach, indigestion, nausea, and diarrhea

Children older than 2 years with mild, infrequent heartburn, acid

indigestion, or sour stomach may try

children’s formulas of calcium carbonate containing antacids

-Children’s Pepto® and Maalox® Children’s Relief Chewable are

two calcium carbonate products

H2RAs are labeled for patients ages 12 years and older, and PPIs

are indicated for patients ages

18 years or older

Pregnant women should initially try

dietary and lifestyle changes

i. Calcium and magnesium containing antacids may be used safely if

the recommended daily dosages are not exceeded

ii. Human data for omeprazole and esomeprazole suggest low risk

with pregnancy

Antacids and H2RAs are indicated fo

mild-moderate heartburn/dyspepsia

while PPIs are indicated for frequent heartburn (occurs > 2 days a week)

PPIs should be used a maximum o

14 days at a time and no more than

every 4 months, and they are not intended for immediate relief of

symptoms