SPECIALISTS IN THIS AREA
Many people will take acid reflux treatment without being formally diagnosed by endoscopy, 24 pH studies or BRAVO pH tests. This may work in the short term, but for most people, particularly if the symptoms last for a significant time or don’t completely recover with medicine, it is important to have formal testing to ensure that the diagnosis is correct.
Acid reflux treatment really contains three essential elements. These are:
Some people are able to manage their heartburn or other reflux symptoms by dietary changes alone. Although many people do not realise it, most episodes of reflux occur in the two hours after eating. The more you eat, the more likely you are to suffer. What is more, if you lie down soon after eating, acid which has gone up into your oesophagus is less likely to clear because gravity is not working for you!
If you suffer, try avoiding large meals or eating late at night. Many people find that avoiding coffee makes a very big difference and don’t forget that chewing sugar free chewing gum for a quarter of an hour just after a meal can help settle the stomach.
For about a quarter of all sufferers, particularly younger people, once the symptoms are under control, they can return to normal and don’t suffer any more.
In many people, however, reflux symptoms do not respond to diet alone. These people need medicines to make them feel better. Medicines can be thought of as those which relieve symptoms and those which prevent reflux in the first place. Many of the modern medicines are highly effective and have almost no side effects.
For the very few people who do not respond to medicine, or who do not want to take drugs long term, anti-reflux surgery is an option. No one wants to opt directly for surgery, and with the array of other treatments now available, this option should really be saved for last.
Indeed, there are now new endoscopic and other minimally invasive approaches to managing reflux. See, for example, the Stretta procedure which we now offer. Around half the patients who undergo this simple, low risk, treatment no longer need to take any acid suppression pills at all.
Acid reflux treatment has improved very significantly over the last 20 years. It should now be possible to help the vast majority of sufferers to return to normal life, and most people should be able to eat quite normally with minimal symptoms.
Acid Reflux Medication
Acid reflux medication can be thought of as including the following categories:
Drugs which neutralise acids
– Simple antacids
– Enhanced antacids with alginates
Drugs which prevent acid production
– H2 receptor antagonists
– Proton pump inhibitors
– New drugs
Simple antacids are useful if you have an attack of heartburn or chest pain. The medicine immediately neutralizes the stomach acid. It works immediately, but the effect also wears off quickly and if the attack is bad, people may need more medicine after only a few minutes
This class includes, amongst others:
- Magnesium or calciumhydroxide, carbonate or trisilicate (which can cause diarrhoea if taken in excess)
- Aluminium hydroxide (which can cause constipation if taken in excess)
- Sodium bicarbonate
- Some preparations include combinations of these medicines. Many of the well known brands for indigestion such as Rennies, Tums Maalox, Mucogel etc are based on combinations of these ingredients.
Enhanced antacids with alginates
Alginates give extra benefits over and above simple antacids.
Alginates contain antacids together with an extra ingredient, the alginate itself. An alginate basically creates a sticky barrier layer, which sits on top of the stomach contents. As a reflux event occurs, stomach contents come back up towards the throat. The alginate barrier comes into contact with the sensitive lining of the oesophagus first. This sticks to the lining and gives a protection from the stomach contents, which follow afterwards. The benefits usually last for around half an hour.
Alginate medicines include Gaviscon and Gastrocote. These can be in liquid or tablet form both of which are effective.
All of these medicines can be bought over the counter at the chemist in the UK.
More powerful medicines can be obtained by prescription, although increasingly, low doses of H2 receptor antagonists (H2RA) and proton pump inhibitors (PPI) can be bought directly over the counter (OTC) as well. Indeed, some OTC medicines now contain combinations of H2RA or PPI together with alginates.
Proton Pump Inhibitors
Proton pump inhibtors (PPIs) work by directly switching off the acid pumps, which live on the surface of the stomach’s acid producing cells, the ‘parietal cells’.
There are five drugs in the PPI class. They are Omeprazole, Lansoprazole, Rabeprazole, Pantoprazole and Esomeprazole.
All these drugs have similar strength (potency), although studies suggest that Esomeprazole (Nexium) may be more powerful than the others at equivalent doses.
How do PPIs work?
New tiny acid pumps (also known as proton pumps) are made by these cells each time a person eats. The more one eats, the more pumps that are made. These pumps create hydrochloric acid and pump it into the body of the stomach where it helps break down the food. They also help to kill any bacteria in the food.
Why does the stomach make acid?
Scientists think that one of the main roles of stomach acid during evolution was to sterilise food before it entered the gut. The need for this has been mostly removed now as most of the food we eat is clean and not infected. In addition, we cook or pickle those foods most at risk of harbouring dangerous bacteria such as meat and fish.
When is the best time to take PPI medicines?
PPIs irreversibly bind the pumps, rendering them useless. New pumps will be made next time the person eats. PPIs exert their effects most strongly in the 30-60 minutes after they are taken, so they have maximum effect if they are swallowed a little while before eating. Overall, these drugs tend to render the stomach acid free for around 12 hours.
Usually, removing acid from the stomach for 12 hours per day, particularly during the daytime, is enough to reduce the acid reflux so that the inflammation that has been caused to the oesophagus can settle. In a small number of people, it is necessary to take the pills twice a day. This allows for the stomach to be free of acid for the entire 24 hour period. Doing this allows inflammation to heal in those people whereas once daily dosing was not adequate.
Are there risks in removing acid from the stomach?
Some people are worried that removing the acid from the stomach can have harmful effects. Click here to find out whether they are right.
In summary, proton pump inhibitors are powerful and effective and large numbers of people find that they need to take them regularly.
Proton Pump Inhibitor Side Effects
Proton pump inhibitors (PPIs) like omeprazole and lansoprazole remove acid from the stomach. Omeprazole side effects are unusual although, like all drugs, there is a long list of things which can trouble people.
The list below is not complete but gives a general guide to some of the side effects that are seen with these drugs.
Common side effects which occur in more than 1% of people who take these medicines are usually mild and include:
- Stomach pain
Risks of Removing Acid from the Stomach
People are often concerned that removing acid from the stomach may cause damage. It is worth remembering that the medicine works for around 12 hours so if taken once a day, the stomach will in fact be acidic for half the day.
Nonetheless, there are some definite small risks associated with taking these drugs long term.
Clostridium difficile diarrhoea is a rare cause of severe diarrhoea. It is frequently contracted in hospitals. Taking a PPI can double the risk.
Pneumonia (chest infections) are also more common in people taking PPIs.
Hip fractures may be more common in people taking PPIs for a long time. The evidence for this is just starting to emerge and it is not yet clear how big, if any, this effect is. Interestingly, one of the sources of this information, the UK General Practice Research database, was analysed a second time and the opposite conclusion was reached, that PPIs do NOT cause an excess in hip fractures. This is definitely an area to keep watching as our understanding improves.
Hypomagnesaemia is a low magnesium level in the blood. This is occasionally seen in people who take proton pump inhibitors long term. It usually responds to stopping the drug.
Heart Rhythm Disturbances have been reported in a recent scientific paper. This is a new description. Time will tell how important or frequent this problem turns out to be. People who have heart rhythm problems should discuss this with their doctor.
Rare side effects can be severe, these include:
- Severe allergic reactions. These might include, amongst other things, shortness of
- breath or a feeling of tightness in the chest, swelling in the mouth, skin rashes or itching.
- bone or chest pain
- dark urine
- fast, slow, or irregular heart beat
- fever, chills, or sore throat
- red, swollen, blistered, or peeling skin
- severe diarrhea, stomach pain or cramps
- swelling of the hands, ankles, or feet
- unusual bruising or bleeding
- unusual or sudden weight increase, tiredness,vision changes or yellowing of the eyes or skin
Stopping Using Proton Pump Inhibitors
In 2009 a report in the prestigious journal, Gastroenterology suggested that PPIs may cause a degree of dependence by increasing symptoms of indigestion if they are discontinued.
In 2010, the American Journal of Gastroenterology reported on healthy volunteers who were given pantoprazole or a dummy pill (placebo) for 4 weeks and then followed for another 6 weeks. One week after they stopped treatment, 44% of the people who had taken pantoprazole reported symptoms of dyspepsia, compared to 9% of the placebo recipients. By the third week, the difference had disappeared.
This suggests that there is rebound excess acid production when the medicines are stopped. It is thought that more of the hormone gastrin is secreted PPIs are stopped and this leads to worsening acid symptoms for a week or two after stopping these drugs.
A case can therefore be made for decreasing the dose of these medicines slowly rather than suddenly discontinuing them. This might be a way to minimise omeprazole side effects and side effects from other proton pump inhibitors.
Latest Medicine News
This page contains latest medicine news for people suffering from heartburn and acid reflux.
For most people, diet, medicines they can buy at the chemist or prescription medicines work very well.
Some people still suffer, however. For many, the reason is that the diagnosis is wrong. They may need the specialist advice of a gastroenterologist who is up to date with the advances in the field.
Even if the diagnosis is correct, not everyone has perfect control of symptoms on acid suppression medicine alone. We know that in some people, the juice refluxing from the stomach into the oesophagus also contains contents from the small bowel (duodenal refluxate). These contents are not acidic. In one study (Gut. 2003;53:1397-1402), administration of the gamma-aminobutyric acid B (GABA B) receptor agonist, baclofen, significantly reduced the amount of duodenal reflux and patients, who had not responded well to PPI therapy, noted a significant improvement in their symptoms.
Baclofen is a γ -aminobutyric acid (GABA) derivative that inhibits the production of transient lower oesophageal sphincter relaxations or TLOSRs by activating the GABAB receptors along the vagovagal reflex arc. It is therefore not surprising that a number of studies suggest that baclofen decreases acid reflux events also.
A number of other GABA B receptor agonists have been investigated, for example lesogaberan. This drug was been developed specifically for gastroesophageal reflux disease. Unfortunately, it was withdrawn during clinical trials.
Another approach is to coat the lining of the oesophagus with a powerful agent which literally sticks to the lining and makes it impervious to the effects of acid. Sucralfate, or Caralfate is one such drug which has been used widely for years and successfully treats both stomach ulcers and the injuries caused by acid reflux.
The problem with this drug is that it is not considered safe to take long term. It is therefore used for only a few weeks at a time under direct supervision of a doctor who is familiar with using it.
Other drugs are being developed and in the next few years, further treatments are likely to become more widely available. It is therefore worth consulting a gastroenterologist who keeps up to date with the latest medicine news.