Chapter 13. Heartburn and Dyspepsia

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Handbook of Nonprescription Drugs > Chapter 13. Heartburn and Dyspepsia
Heartburn and Dyspepsia: Introduction
Heartburn (pyrosis) is one of the most common gastrointestinal complaints. It is often described as a burning sensation in the
stomach or lower chest that rises up toward the neck and occasionally to the back.1 Patients may also describe it as indigestion,
acid regurgitation, sour stomach, or bitter belching. Heartburn is a common symptom of gastroesophageal reflux disease
(GERD), but similar symptoms may also occur in patients with peptic ulcer disease (PUD), delayed gastric emptying, gallbladder
disease, and numerous other gastrointestinal disorders. Dyspepsia is defined as symptoms originating from the gastroduodenal
region and includes bothersome postprandial fullness, early satiation, epigastric pain, and epigastric burning.2 Patients with
dyspepsia may report many of these symptoms, as well as anorexia, belching, nausea and vomiting, and upper abdominal
bloating. Heartburn can also occur with dyspepsia. Dyspepsia can be organic, meaning it has an identifiable cause, or
functional. Patients with functional dyspepsia have no identifiable organic, systemic, or metabolic disease that is likely to explain
the dyspeptic symptoms.
Although rarely a cause of mortality, dyspepsia, heartburn, and GERD are associated with considerable morbidity and cost.
Patients with heartburn may limit their activities and restrict their food choices to reduce symptom frequency and severity.
Compared with the general population, patients with heartburn have an impaired quality of life, with symptoms affecting activity
and work.3 Nocturnal symptoms of heartburn were reported in 24.9% of the general population and in 74%-79% of patients with
heartburn that occurs at least once a week.4 Nocturnal symptoms are associated with interrupted sleep, decreased health-
related quality of life, decreased work productivity, increased daytime sleepiness, and increased complications such as erosive
esophagitis and stricture.4 Patients with dyspepsia report a diminished quality of life similar to patients with mild heart failure or
menopause.5 A retrospective analysis of health insurance claims showed that patients with functional dyspepsia incurred $5138
more in annual costs than people without dyspepsia.5 The total direct and indirect costs for GERD were over $12.6 billion per
year; a large percentage of the costs were for prescription medications.1
The prevalence of heartburn and acid regurgitation in the past year in a healthy, predominantly white population were 42% and
45%, respectively.1 Weekly symptoms were reported by 20% of the population, with an equal gender distribution.1 Most subjects
reported their heartburn to be moderately severe. In a cross-sectional study, the prevalence of heartburn was similar among
African Americans, Hispanics, Asians, and whites (23%-27%).1 However, whites had significantly more esophagitis. Although
men and women are almost equally affected by GERD, males have a higher rate of esophagitis and Barretts esophagus (a
precancerous condition). Older patients have a higher prevalence of GERD complications, but they may experience fewer
symptoms because of decreased sensitivity to refluxed acid. The prevalence of GERD has been increasing in Western countries
over the past 30 years, while remaining relatively low among residents of Africa and Asia. The rise in Western countries is
speculated to be a result of increasing obesity and decreasing prevalence of Helicobacter pylori infection.1 Heartburn is
common during pregnancy, with 30%-80% of women complaining of heartburn, especially in the first trimester.1
Prevalence of dyspepsia has been estimated to range between 10% and 45%.2 Much of this variation is influenced by criteria
used to define dyspepsia. When heartburn is excluded, the prevalence of uninvestigated dyspepsia is 5%-15%. Women have a
slightly higher prevalence compared with men. The incidence of dyspepsia has been estimated to be 2.8% per year.5 Among
patients with dyspepsia, 5%-10% have a peptic ulcer and approximately 20% have erosive esophagitis.
Pathophysiology
Esophageal defense mechanisms (antireflux barriers, esophageal acid clearance, and tissue resistance) help protect the
esophageal mucosa from acid damage. Antireflux barriers include the intrinsic lower esophageal sphincter (LES), the
diaphragmatic crura, the intra-abdominal location of the LES, the phrenoesophageal ligaments, and the acute angle of His
(Figure 13-1). These anatomic structures work together to provide a physical barrier against gastric contents being refluxed into
the esophagus. The major component is the LES, the distal 3-4 cm of the esophagus that is contracted at rest. The LES relaxes
on swallowing to permit the flow of food, liquids, and saliva into the stomach. Transient relaxations occur when there is no
swallowing or esophageal peristalsis, allowing retrograde movement of stomach contents into the esophagus. The crural
diaphragm provides an extrinsic squeeze to the LES, contributing to resting pressure and augmenting LES pressure during
periods of increased abdominal pressure, such as with coughing, sneezing, or bending over. The angle of His creates a flap
valve effect that contributes to the antireflux barrier.
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Esophageal defense mechanisms and offensive factors associated with heartburn.

When reflux of acidic gastric material does occur, physiologic mechanisms help protect the esophageal mucosa from damage.
Esophageal acid clearance occurs when peristalsis moves refluxed material into the stomach, and saliva and esophageal gland
secretions neutralize residual acid. Gravity also helps clear the esophagus. Tight junctions and the matrix of lipid-rich
glycoconjugates in the intercellular space reduce epithelial damage from hydrogen ions. Epithelial cells are also capable of
buffering and extruding hydrogen ions that do penetrate the cell membrane. Tissue resistance is further aided by the
esophageal blood supply that delivers oxygen, nutrients, and bicarbonate and removes hydrogen and carbon dioxide,
maintaining normal tissue acid-base balance. Even though gastroesophageal reflux is common, particularly postprandially,
symptoms and esophageal damage are uncommon because of these esophageal defense mechanisms.
Heartburn is likely related to stimulation of esophageal mucosal chemoreceptors. Heartburn symptoms can arise from acid
reflux, weakly acidic reflux, bile reflux, and mechanical stimulation of the esophagus. It is unclear why some reflux episodes
produce symptoms whereas most do not. Possible contributing factors include mucosal disruption, decreased acid clearance,
inflammation, reduced salivary bicarbonate concentration, volume of refluxate, frequency of heartburn, and interaction of pepsin
with acid. One theory is that the esophagus becomes hypersensitive from repeated acid exposure, causing symptoms to occur
from smaller boluses of acid.6 Any disruption in the esophageal defense mechanisms can lead to increased acid exposure.
Distension of the proximal stomach by either food or gas is a major stimulus for transient LES relaxations. Some patients may
have a relatively hypotensive LES that can be overcome by an abrupt increase in intra-abdominal pressure from coughing,
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straining, or bending over. A hiatal hernia impairs LES function and esophageal acid clearance. A hiatal hernia displaces the
LES from the crural diaphragm, reduces LES pressure, and results in more frequent transient relaxations of the LES, all of
which contribute to increased reflux. Prolonged exposure of the esophagus to the refluxed material can occur when lying down
or sleeping and with decreased salivation or with peristaltic dysfunction. Large refluxate volumes from overeating or delayed
gastric emptying can also increase esophageal acid exposure. As a result, damage to the tight intercellular junctions of the
esophageal mucosa can lead to increased cellular permeability to hydrogen ions, with subsequent cellular injury. This increased
permeability partly explains the development of heartburn in the absence of overt esophagitis.1 The composition of the refluxate
is an important contributor to the degree of esophageal damage. Pepsin and/or bile salts combined with acid produce greater
injury than acid alone. Helicobacter pylori infection lowers gastric acidity, thereby possibly protecting against heartburn, GERD,
and related complications.1
A number of risk factors are weakly associated with the development of heartburn (Table 13-1).1,6,7,8 Foods (e.g., fat, chocolate,
peppermint) and drugs (e.g., theophylline, morphine, calcium channel blockers, diazepam) can decrease LES pressure, leading
to increased reflux. Foods such as citrus, tomato-based foods, and spicy foods can irritate inflamed esophageal mucosa.
Smoking contributes by relaxing LES pressure and decreasing salivation. Anxiety, fear, and worry may lower visceral sensitivity
thresholds, leading to increased pain perception. Bending over, straining to defecate, lifting heavy objects, and performing
isometric exercises may increase intra-abdominal pressure above the LES pressure, leading to reflux. Obesity increases intra-
abdominal pressure, and epidemiologic studies suggest that the prevalence of GERD is considerably higher in obese patients
than in those with a normal body mass index.1
TABLE 13-1 Risk Factors That May Contribute to Heartburn
Dietary Medications
Alcohol (ethanol) Alpha-adrenergic antagonists
Caffeinated beverages Anticholinergic agents
Carbonated beverages Aspirin/NSAIDs
Chocolate Barbiturates
Citrus fruit or juices Benzodiazepines
Coffee Beta2-adrenergic agonists
Fatty foods Bisphosphonates
Garlic or onions Calcium channel blockers
Mint (e.g., spearmint, peppermint) Chemotherapy
Salt and salt substitutes Clindamycin
Spicy foods Dopamine
Tomatoes/tomato juice Doxycycline
Estrogen
Lifestyle Iron
Exercise (isometric, running) Narcotic analgesics
Obesity Nitrates
Smoking (tobacco) Potassium
Stress Progesterone
Supine body position Prostaglandins
Tight-fitting clothing Quinidine
Diseases TCAs
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Dietary Medications
Motility disorders (e.g., gastroparesis) Tetracycline
PUD Theophylline
Scleroderma Zidovudine
Zollinger-Ellison syndrome Other
Genetics
Pregnancy
Key: NSAID = Nonsteroidal anti-inflammatory drug; PUD = peptic ulcer disease; TCA = tricyclic antidepressant.
Source: References 1, and 6-8.
Dyspepsia may be caused by PUD, GERD, celiac disease, gastric or esophageal malignancy (rarely), or other gastrointestinal
(GI) disorders. Specific foods, such as spicy food, coffee, or alcohol, or excessive food intake have not been established as
causing dyspepsia. Medications, including iron, antibiotics, narcotics, digoxin, estrogens, theophylline, and nonsteroidal
anti-inflammatory drugs (NSAIDs), commonly cause dyspepsia through direct gastric mucosal injury, changes to GI function,
exacerbation of reflux, or some other mechanism.2 The pathophysiology of functional dyspepsia is unclear but may include
delayed gastric emptying, impaired gastric accommodation to a meal, hypersensitivity to gastric distension, altered duodenal
sensitivity, abnormal intestinal motility, and central nervous system dysfunction.2 One or more of these disturbances can occur
in individual patients. The cause of symptoms in patients with functional dyspepsia has not been established. Population studies
have suggested a genetic predisposition. H. pylori may play a role in functional dyspepsia, as evidenced by the small
improvement in symptoms following eradication. Patients who have recovered from gastroenteritis may suffer from postinfection
functional dyspepsia. Psychosocial factors are an important contributor to symptom severity. Patients with functional dyspepsia
may also have anxiety disorders, depression, somatoform disorders, and a recent or remote history of physical or sexual abuse.
The exact mechanism is unknown, but some studies have suggested a relationship between psychosocial factors and visceral
hypersensitivity.2
Clinical Presentation
Heartburn may occur alone or be associated with other GI disorders such as GERD and PUD (Table 13-2). Heartburn is most
frequently noted within 1 hour after eating, especially after a large meal or ingestion of offending foods and/or beverages. Lying
down or bending over may exacerbate heartburn. Regurgitation and, less commonly, water brash may also occur. Regurgitation
is characterized by a bitter acidic fluid in the back of the throat. It is more common at night or when bending over. It differs from
vomiting: nausea, retching, or abdominal contractions do not occur. Water brash is the sudden filling of the mouth with clear,
slightly salty fluid secreted from the salivary glands. Severity of any of these symptoms is subjective, and no standard definitions
exist for classifying symptoms as mild, moderate, or severe. Symptoms may be considered mild if they bother the patient a little
but do not interfere with normal activities. Symptoms that are somewhat bothersome or annoying and/or interfere with normal
activities may be considered moderate. Heartburn occurring two or more times a week is suggestive of GERD.1 GERD can be
complicated by erosive esophagitis, hemorrhage, esophageal ulcers, strictures, Barretts esophagus, and esophageal
adenocarcinoma. Heartburn severity is poorly correlated with esophageal damage, especially in older patients who may have no
or mild symptoms despite severe erosive esophagitis or other complications on presentation. 1 Upper endoscopy is the standard
for determining the presence and extent of esophageal damage.
TABLE 13-2 Differentiation of Simple Heartburn from Other Acid-Related Disorders
Simple Heartburn GERD Dyspepsia PUD
Etiology See Table 13-1 See Table Possible contributing factors: Gastric or duodenal ulcer
13-1 food, alcohol, caffeine, stress, caused most commonly by
and medications Helicobacter pylori infection
Chronic dyspepsia: associated and/or NSAIDs
with PUD, GERD, celiac
disease, and gastric cancer; or
may lack an identifiable cause
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Simple Heartburn GERD Dyspepsia PUD
(functional dyspepsia)
Typical Burning sensation behind Heartburn, Primary: postprandial fullness, Gnawing or burning epigastric
symptoms the breastbone that may acid early satiation, epigastric pain, pain, occurring during day and
radiate toward the neck, regurgitation epigastric burning frequently at night; may be
throat, and occasionally Other: belching, bloating, accompanied by heartburn and
the back nausea, vomiting dyspepsia
Key: GERD = Gastroesophageal reflux disease; GI = gastrointestinal; NSAID = nonsteroidal anti-inflammatory drug; PUD =
peptic ulcer disease.
Alarm symptoms include dysphagia, odynophagia, upper GI bleeding, and unexplained weight loss, and they can indicate more
severe disease and/or complications. Dysphagia (difficulty swallowing) is slowly progressive for solid food and is usually
associated with long-standing heartburn. The most common causes are peptic stricture or Schatzkis ring, but severe
esophagitis, peristaltic dysfunction, and esophageal cancer are other potential etiologies.1 Odynophagia (painful swallowing) is
less common and may indicate severe ulcerative esophagitis, pill injury (e.g., tetracycline, potassium chloride, vitamin C,
NSAIDs, aspirin, or bisphosphonates), or infection. Signs of upper GI bleeding include hematemesis, melena, occult bleeding,
and anemia. Patients may also present with atypical or extraesophageal symptoms related to gastroesophageal reflux. These
include noncardiac chest pain, asthma, laryngitis, hoarseness, globus sensation (sensation of a lump in the throat), chronic
cough, recurrent pneumonitis, and dental erosion.1,9 Patients presenting with any alarm symptoms or atypical symptoms should
be referred to their primary care provider for further evaluation.
Dyspepsia can present with one or more of four main symptoms. Postprandial fullness is an unpleasant sensation perceived as
the prolonged persistence of food in the stomach. Early satiation is the feeling of fullness soon after starting to eat that is out of
proportion to the amount of food ingested. Early satiety was the term previously used, but satiation is the correct term according
to the most recent diagnostic criteria.2 Epigastric pain is an unpleasant sensation between the umbilicus and lower end of the
sternum. Epigastric burning refers to an unpleasant subjective sensation of heat. Less specific symptoms may include bloating,
nausea, vomiting, and belching. Symptoms are mostly intermittent and may or may not be related to meals. Weight loss is
considered an alarm symptom that should prompt referral for further investigation. Other alarm symptoms include anemia, blood
loss, and dysphagia.
Treatment of Heartburn and Dyspepsia
Treatment Goals
The goals of self-treatment of heartburn and dyspepsia are to (1) provide complete relief of symptoms, (2) reduce recurrence of
symptoms, and (3) prevent and manage unwanted effects of medications.
General Treatment Approach
The approach to self-treatment of heartburn and dyspepsia requires an initial assessment to determine whether the patient is a
candidate for self-care (Figure 13-2). Individuals with exclusions for self-treatment should be referred for further medical
evaluation. If the individual is a candidate for self-treatment, specific nondrug measures should be recommended and continued
throughout treatment (see Patient Counseling for Heartburn and Dyspepsia). If appropriate, a recommendation should also be
made for a nonprescription medication. The selection of the medication should be based on the frequency, duration, and
severity of symptoms; the cost of the medication; potential drug-drug interactions and adverse effects; and the patients
preference. Antacids and nonprescription histamine type 2 receptor antagonists (H2RAs) should be recommended for
individuals with mild, infrequent heartburn and dyspepsia. Antacids are advantageous because they provide rapid relief of
symptoms, but relief is brief when taken on an empty stomach (Table 13-3). When used in recommended dosages, the antacids
are interchangeable despite differences in antacid salts and potency. Antacid/alginic acid combinations have a comparable
onset of action to that of antacids alone and may provide better relief and a slightly longer duration of action.10,11
A nonprescription H2RA is preferred to an antacid when individuals with mild-moderate episodic heartburn require more
prolonged relief of symptoms. H2RAs do not relieve heartburn or dyspepsia as rapidly as an antacid (Table 13-3) but may be
used with an antacid if quick relief is desired along with a longer duration of action. The H 2RAs may also be used to prevent
heartburn and acid indigestion when given 30 minutes to 1 hour prior to situations in which heartburn is anticipated.
Nonprescription H2RA products containing the lower doses (e.g., famotidine 10 mg up to twice daily) should be recommended
for patients with mild, infrequent heartburn, whereas higher nonprescription dosages (e.g., famotidine 20 mg up to twice daily)
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should be reserved for moderate symptoms. Patients should not exceed 14 days of self-treatment with an H2RA without
consulting their primary care provider.
Nonprescription proton pump inhibitors (PPIs) can be used for treating frequent heartburn (2 or more days per week) or when
patients do not respond to nonprescription H2RAs.12 The onset of symptomatic relief following a PPI dose is slower than that of
an H2RA (Table 13-3), and complete relief of symptoms may take several days after initiation of therapy. However, PPIs provide
better symptomatic relief and a prolonged duration of action compared with the H2RAs. When used to self-treat, the PPI should
be limited to a duration of 14 days and retreatment to every 4 months.
Nonpharmacologic Therapy
Nonpharmacologic measures may benefit some individuals, but these changes alone are unlikely to completely relieve
symptoms in the majority of patients. Dietary and lifestyle modifications recommended for heartburn are aimed at avoiding foods
and beverages that precipitate heartburn and adopting behaviors that reduce esophageal acid exposure. Nonpharmacologic
measures should be recommended for all patients with heartburn and dyspepsia despite the fact that evidence supporting their
effectiveness is either lacking or equivocal.5,7,8 A complete and accurate history will assist in identifying contributing factors
(Table 13-1). Individuals should be asked to keep a diary to track dietary, lifestyle, and medication triggers. Recommendations
should be tailored to the individuals specific history. Weight loss should be advised for overweight patients with heartburn.
Elevating the head of the bed by placing 6- to 8-inch blocks underneath the legs at the head of the bed or placing a foam wedge
(e.g., GERD pillow) beneath the patients upper torso and head should be recommended for patients troubled with heartburn
when recumbent. Use of traditional pillows may worsen symptoms because they cause the individual to bend at the waist, which
contributes to an increase in intragastric pressure.
Individuals should be educated about factors that contribute to heartburn and be advised how to manage them (see the box
Patient Education for Heartburn and Dyspepsia). Most important, heartburn sufferers should be counseled to eat smaller meals,
to reduce intake of dietary fat, and to refrain from eating within 3 hours of going to bed or lying down. Prescription and
nonprescription medications should be evaluated for their potential to cause or exacerbate heartburn and dyspepsia (Table
13-1). When possible, individuals should be advised to switch to less troublesome nonprescription medications or to consult
their prescriber about prescription drugs that may be exacerbating their symptoms. Use of tobacco products should be
discouraged. If alcohol or caffeine consumption is a contributing factor, individuals should be advised to limit or discontinue use.
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Self-care of heartburn. Key: H2RA = Histamine type 2 receptor antagonist; OTC = over-the-counter; PPI = proton pump inhibitor.
TABLE 13-3 Onset and Duration of Symptomatic Relief with Nonprescription Medications in Relieving Heartburn
Medication Onset of Relief Duration of Relief
Antacids <5 minutes 20-30 minutesa
H2RAs 30-45 minutes 4-10 hours
H2RA + antacid <5 minutes 8-10 hours
PPIs 2-3 hours 12-24 hours
Key: H2RA = Histamine type 2 receptor antagonist; PPI = proton pump inhibitor.
a Food prolongs duration of relief.
Pharmacologic Therapy
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Antacids
Antacids relieve heartburn and dyspepsia by neutralizing gastric acid. Nonprescription antacid products contain at least one of
the following salts: magnesium (hydroxide, carbonate, or trisilicate); aluminum (hydroxide or phosphate); calcium carbonate; or
sodium bicarbonate (Table 13-4). Most antacids are relatively inexpensive, making them affordable products for the temporary
relief of mild and infrequent heartburn and dyspepsia.
TABLE 13-4 Selected Nonprescription Antacid and Bismuth Products and Dosage Regimens
Trade Name Primary Ingredients Dosage (maximum daily dosage)
Adults/Children 12 Years
Alka-Seltzer Heartburn Sodium bicarbonate 1940 mg; citric acid 1000 Dissolve 2 tablets in 4 ounces of water every 4
Relief mg hours as needed (8 tablets)
Alka-Seltzer Original Sodium bicarbonate 1916 mg; citric acid 1000 Dissolve 2 tablets in 4 ounces of water every 4
mg; aspirin 325 mg hours as needed (8 tablets)
Gaviscon Regular Each 15 mL containsa aluminum hydroxide 95 1-4 tablespoons 4 times a day, after meals and
Strength Liquid mg; magnesium carbonate 358 mg at bedtime (16 tablespoons)
Gelusil Tablets Aluminum hydroxide 200 mg; magnesium Chew 2-4 tablets; repeat hourly if symptoms
hydroxide 200 mg; simethicone 25 mg return (12 tablets)
Mylanta Ultimate Strength Each 5 mL contains aluminum hydroxide 500 2-4 teaspoons between meals and at bedtime
Liquid mg; magnesium hydroxide 500 mg (9 teaspoons)
Mylanta Supreme Liquid Each 5 mL contains calcium carbonate 400 2-4 teaspoons between meals and at bedtime
mg; magnesium hydroxide 135 mg (18 teaspoons)
Pepto-Bismol Maximum Each 15 mL contains bismuth subsalicylate 2 tablespoons every 1 hour as required (4
Strength Liquid 525 mg doses or 8 tablespoons)
Pepto-Bismol Original Each 15 mL contains bismuth subsalicylate 2 tablespoons every 30 minutes to 1 hour as
Liquid 262 mg required (8 doses or 16 tablespoons)
Rolaids Regular Strength Calcium carbonate 550 mg; magnesium Chew 2-4 tablets hourly as needed (12 tablets)
Antacid Tablets hydroxide 110 mg
Tums Extra 750 Tablets Calcium carbonate 750 mg Chew 2-4 tablets as needed for symptoms (10
tablets)
Tums Regular Strength Calcium carbonate 500 mg Chew 2-4 tablets as needed for symptoms (15
Tablets tablets)
Children 12 Years
Maalox Childrens Calcium carbonate 400 mg Age 2-5 years: 1 tablet (3 tablets)
Relief Chewable Age 6-11 years: 2 tablets (6 tablets)
Childrens Pepto Calcium carbonate 400 mg Age 2-5 years: 1 tablet (3 tablets)
Age 6-11 years: 2 tablets (6 tablets)
a Sodium alginate (alginic acid) is listed as an inactive ingredient.
Antacids act as buffering agents in the lower esophagus, gastric lumen, and duodenal bulb. The cations react with chloride, but
the anionic portion of the molecule reacts with hydrogen ions to form water and other compounds. Sodium bicarbonate rapidly
reacts with gastric acid to form sodium chloride, carbon dioxide, and water. Its duration of action is shortened by its quick
elimination from the stomach.13 Of the magnesium salts, magnesium hydroxide is used most often. Magnesium hydroxide
rapidly reacts with gastric acid to form magnesium chloride and water. This agent has a shorter duration of action than that of
calcium carbonate and aluminum hydroxide. Calcium carbonate is a potent antacid that dissolves slowly in gastric acid to form
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calcium chloride, carbon dioxide, and water. This agents onset of action is slower, but its duration of effect is longer than that of
magnesium hydroxide or sodium bicarbonate. Aluminum hydroxide reacts with hydrochloric acid to form aluminum chloride and
water. This agent has a slower onset and a longer duration than those of magnesium hydroxide. As a result of these reactions, a
small but noticeable increase in intragastric pH occurs. Increasing the intragastric pH above 5 blocks the conversion of pepsin to
pepsinogen.13 Antacids also increase LES pressure.1
Liquid antacids usually have a faster onset than tablets because they are already dissolved or suspended and provide a
maximal surface area for action. Of the tablet dosage forms, the quick-dissolving antacid tablets may provide the most rapid
relief of symptoms. The duration of action for all antacids is transient, lasting only as long as the antacid remains in the stomach.
The presence of food affects the duration of action of antacids. When administered within 1 hour after a meal, antacids may
remain in the stomach for up to 3 hours.13
Differences in antacids are determined primarily by the cation, specific salt, and potency. Antacid potency is based on the
number of milliequivalents of acid neutralizing capacity (ANC), which is defined as the amount of acid buffered per dose over a
specified period of time. Factors that contribute to the ANC include product formulation, ingredients, and concentration.13 As a
result, the ANC is product specific; the same number of antacid tablets or equal volumes of different liquid antacids are not
necessarily equal in potency.
Most antacids are minimally absorbed into the systemic circulation.13 Approximately 90% of calcium is converted to insoluble
calcium salts; the remaining 10% is absorbed systemically. About 15%-30% of magnesium and 17%-30% of aluminum may be
absorbed and then excreted renally; therefore, accumulation may occur in patients with renal insufficiency. Sodium bicarbonate
is readily absorbed and is eliminated renally.
Antacids are indicated for the treatment of mild, infrequent heartburn, sour stomach, and acid indigestion. Combination products
containing aspirin or acetaminophen are FDA approved for overindulgence in food and drink and for hangover, although
effectiveness has not been demonstrated. Individuals with mild dyspepsia may experience some relief with antacids, but no
studies demonstrate their effectiveness.2
Antacids are administered orally. The effective dose of an antacid varies depending on product ingredients, milliequivalents of
ANC, formulation, and the frequency and severity of symptoms. Individuals should be instructed to take product-specific
recommended doses at the onset of symptoms. Dosing may be repeated in 1-2 hours, if needed, but should not exceed the
maximum daily dosage for a particular product (Table 13-4). Individuals should be reevaluated if antacids are used more than
twice a week or regularly for more than 2 weeks. Frequent antacid users may need to be switched to a longer-acting product
such as an H2RA, an H2RA plus an antacid, or a PPI.
Antacids are usually well tolerated. Side effects are generally associated with the cation. The most common side effect
associated with magnesium-containing antacids is dose-related diarrhea. Diarrhea may be reduced by combining magnesium-
containing antacids with aluminum hydroxide. However, when higher dosages are used, the predominating effect is diarrhea.
Magnesium excretion is impaired in patients with renal disease and may result in systemic accumulation of magnesium.
Magnesium-containing antacids should not be used in patients with a creatinine clearance of less than 30 mL/minute.13
Aluminum-containing antacids are associated with dose-related constipation. Aluminum hydroxide binds dietary phosphate in
the GI tract, increasing phosphate excretion in the feces. Frequent and prolonged use of aluminum hydroxide may lead to
hypophosphatemia.13 Chronic use of aluminum-containing antacids in patients with renal failure may lead to aluminum toxicity
and should be avoided.
Calcium carbonate may cause belching and flatulence as a result of carbon dioxide production. Constipation when taking
calcium antacids has been reported, but there is little evidence to support this side effect.14 Calcium stimulates gastric acid
secretion and is hypothesized to cause acid rebound when calcium-containing antacids are used to treat acid-related disorders.
The clinical importance of this finding, however, remains uncertain.13 If renal elimination is impaired, hypercalcemia may occur,
and accumulation of calcium may result in the formation of renal calculi. Because many antacids have been reformulated to
contain calcium, there is a risk of hypercalcemia when high and frequent dosages of calcium-containing antacids are taken with
other calcium supplements or foods such as milk or orange juice with added calcium. Up to 2500 mg/day of elemental calcium
can be ingested safely in individuals with normal renal function.15 (See Chapter 22 for a discussion of calcium supplementation.)
Sodium bicarbonate frequently causes belching and flatulence that result from the production of carbon dioxide.13 The high
sodium content (274 mg sodium/gram sodium bicarbonate) may cause fluid overload in patients with congestive heart failure,
renal failure, cirrhosis, or pregnancy, and in those on sodium-restricted diets. Individuals with normal renal function excrete
additional bicarbonate, whereas patients with impaired renal function retain bicarbonate, which may cause systemic alkalosis. A
high intake of calcium along with an alkalinizing agent (e.g., sodium bicarbonate or calcium carbonate) may lead to
hypercalcemia, alkalosis, irritability, headache, nausea, vomiting, weakness, and malaise (milk-alkali syndrome).13 Individuals
who take calcium supplements should avoid using sodium bicarbonate as an antacid.
When given concomitantly with other oral medications, all antacids may potentially increase or decrease the absorption of the
other medications by adsorbing or chelating the other drugs or by increasing intragastric pH.16 Medications such as
tetracyclines, azithromycin, and fluoroquinolones bind to divalent and trivalent cations, potentially decreasing antibiotic
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absorption. Absorption of levothyroxine may be decreased in the presence of an antacid; therefore, it is recommended to
separate doses by 4 hours. The absorption of medications such as itraconazole, ketoconazole, and iron, which depend on a low
intragastric pH for disintegration, dissolution, or ionization, may also be decreased. Specific antacids, such as aluminum
hydroxide, may decrease the absorption of isoniazid. Premature breakdown of enteric-coated products may be increased with
concurrent administration of antacids. The intraluminal interactions of antacids with other oral medications can usually be
avoided when potentially interacting drugs are separated by at least 2 hours. Antacid-induced alkalization of the urine may
increase urinary excretion of salicylates and decrease blood concentrations.16 In contrast, an increase in urine pH may
decrease urinary excretion and increase blood concentrations of amphetamines and quinidine.13
Alginic acid reacts with sodium bicarbonate in saliva to form a viscous layer of sodium alginate that floats on the surface of
gastric contents, forming a protective barrier against esophageal irritation. Although alginic acid does not neutralize acid, the
combination of alginic acid and antacid may provide better symptomatic relief than the antacid alone.11 Because there is
insufficient evidence supporting its efficacy as a single agent, the Food and Drug Administration (FDA) has not granted alginic
acid Category I status. However, alginic acid may be found as an inactive ingredient in several antacid products (Table 13-4).
Some antacid products contain simethicone to decrease discomfort related to intestinal gas. (See Chapter 14 for a more
detailed description of simethicone.)
Histamine Type 2 Receptor Antagonists
Cimetidine, ranitidine, famotidine, and nizatidine are approved for nonprescription use (Table 13-5) at one-half of the prescription
dose and at the lower prescription dose. Products containing nizatidine are not currently available in the United States. When
used in recommended dosages, the H2RAs are considered interchangeable despite minor differences in potency, onset,
duration of symptomatic relief, and side effects. The H2RAs decrease fasting and food-stimulated gastric acid secretion and
gastric volume by inhibiting histamine on the histamine type 2 receptor of the parietal cell. Therefore, the H2RAs are effective in
relieving fasting and nocturnal symptoms.17 Their bioavailability is not affected by food but may be reduced modestly by
antacids. Onset of symptomatic relief is not as rapid as with antacids, but the duration of effect is longer (Table 13-3). Cimetidine
is the shortest acting (4-8 hours); ranitidine, famotidine, and nizatidine have a somewhat longer duration. Tolerance to the
gastric antisecretory effect may develop when H2RAs are taken daily (versus as needed) and may be responsible for diminished
efficacy.18 Therefore, it is preferable to take an H 2RA on an as-needed basis rather than regularly every day. All four H2RAs are
eliminated by a combination of renal and hepatic metabolism, with renal elimination being the most important. A reduced daily
H 2RA dose should be considered in patients with impaired renal function (creatinine clearance of less than 50 mL/minute) and
patients of advanced age.17
Nonprescription H2RAs are indicated for the treatment of mild-moderate, infrequent, or episodic heartburn and for the prevention
of heartburn associated with acid indigestion and sour stomach. H2RAs are more effective than placebo for relief of
mild-moderate heartburn and provide moderate improvement in patients with mild, infrequent uninvestigated dyspepsia.5 H2RAs
may be used at the onset of symptoms or 30 minutes to 1 hour prior to an event (e.g., meal or exercise) in which heartburn is
anticipated. The combined H 2RA and antacid product (famotidine plus magnesium hydroxide and calcium carbonate; see Table
13-5) is indicated for individuals with postprandial heartburn who have not premedicated with an H2RA. This combined product
provides immediate relief and a longer duration of effect. Self-treatment dosing should be limited to no more than 2 times a day.
If self-treatment with an H 2RA is needed for more than 2 weeks, a medical referral is recommended.
H 2RAs are well tolerated and have a low incidence of side effects. The most common side effects reported with all four H2RAs
include headache, diarrhea, constipation, dizziness, and drowsiness. Thrombocytopenia is a rare but serious adverse event with
all four H2RAs, but this effect is reversible upon discontinuation of the drug. Cimetidine is associated with a weak antiandrogenic
effect that, when taken in high doses, may result in decreased libido, impotence, or gynecomastia in men.
TABLE 13-5 Selected Nonprescription H2RA and PPI Products and Dosage Regimens
H2RA Products (Adults/Children 12 Years)
Tagamet HB, various Cimetidine 200 mg 1 tablet with a glass of water (2 tablets)
generic
Pepcid AC, various Famotidine 10 mg 1 tablet with a glass of water (2 tablets)

generic
Pepcid AC Maximum Famotidine 20 mg 1 tablet with a glass of water (2 tablets)

Strength, various generic
10 of 22 3/15/2015 1:19 AM
H2RA Products (Adults/Children 12 Years)
Pepcid Complete Famotidine 10 mg; calcium carbonate 800 Chew and swallow 1 tablet (2 tablets)
mg; magnesium hydroxide 165 mg
Tums Dual Action Famotidine 10 mg; calcium carbonate 800 Chew and swallow 1 tablet (2 tablets)
mg; magnesium hydroxide 165 mg
Zantac 75, various generic Ranitidine 75 mg 1 tablet with a glass of water (2 tablets)
Zantac 150, various Ranitidine 150 mg 1 tablet with a glass of water (2 tablets)
generic
PPI Products (Adults 18 Years)
Prilosec OTC, various Omeprazole magnesium 20.6 mg 1 tablet with a glass of water 30 minutes before
generic morning meal; take daily for 14 days (1 tablet)
Zegerid Omeprazole 20 mg; sodium bicarbonate 1 capsule with a glass of water 1 hour before
1100 mg morning meal; take daily for 14 days (1 capsule)
Prevacid 24HR, various Lansoprazole 15 mg 1 capsule with a glass of water 30 minutes before
generic morning meal; take daily for 14 days (1 capsule)
Nexium 24HR Esomeprazole 20 mg 1 capsule with a glass of water 30 minutes before

morning meal; take daily for 14 days (1 capsule)
Cimetidine inhibits several hepatic cytochrome P450 (CYP450) isoenzymes (3A4, 2D6, 1A2, and 2C9), resulting in drug
interactions with numerous medications (e.g., phenytoin, warfarin, theophylline, tricyclic antidepressants, and amiodarone).16
Cimetidine also inhibits CYP2C19 and blocks the conversion of clopidogrel to its active form, thus possibly reducing the
effectiveness of clopidogrel.20 CYP450 drug interactions with ranitidine, nizatidine, and famotidine are uncommon at
nonprescription doses. Medications such as ketoconazole, itraconazole, indinavir and atazanavir, and iron salts require an acidic
environment for absorption.16,21 When administered with an acid-reducing drug, their absorption may be reduced. Cimetidine
may inhibit the renal tubular secretion of drugs such as procainamide, metformin, and dofetilide.
Proton Pump Inhibitors
PPIs are potent antisecretory drugs that relieve heartburn and dyspepsia by decreasing gastric acid secretion. They inhibit
hydrogen potassium ATPase (the proton pump), irreversibly blocking the final step in gastric acid secretion, thus providing a
more potent and prolonged antisecretory effect than that of the H2RAs (Table 13-3).17 The relative bioavailability of PPIs
increases with continued daily dosing. Onset of symptomatic relief following an oral dose may occur in 2-3 hours, but complete
relief may take 1-4 days.22 The PPIs are almost completely absorbed after oral administration, regardless of the presence of
food.17
Omeprazole magnesium 20.6 mg (Prilosec OTC), the first PPI to become available for nonprescription use in the United States
(Table 13-5), is available as a delayed-release tablet containing enteric-coated pellets (protection against intragastric
degradation) and is converted in the body to omeprazole 20 mg.17 Nonprescription omeprazole is also available as specific
pharmacy-branded products. Immediate-release omeprazole (Zegerid) is formulated with omeprazole 20 mg and sodium
bicarbonate 1100 mg. The sodium bicarbonate in Zegerid raises intragastric pH, permitting rapid absorption of omeprazole from
the duodenum, but there is insufficient evidence to confirm that this results in a quicker onset of symptomatic relief.
Esomeprazole magnesium 22.3 mg (Nexium 24HR) is the S-isomer of omeprazole and is available as a delayed-release
capsule. Lansoprazole 15 mg (Prevacid 24HR) is available as a capsule formulation containing enteric-coated granules.
Differences in efficacy among the PPIs have not been established. PPI tablets and capsules should not be chewed or crushed
because the enteric coating will be compromised, thus decreasing the effectiveness of the drug.17
Nonprescription PPIs are indicated for the treatment of frequent heartburn in patients who have symptoms 2 or more days a
week. They are not intended for immediate relief of occasional or acute episodes of heartburn and dyspepsia. Because PPIs
inhibit only those proton pumps that are actively secreting acid, they are most effective when taken 30-60 minutes before a
meal, preferably before breakfast.23 Self-treatment should be limited to 14 days and no more frequently than every 4 months. If
heartburn continues while taking a nonprescription PPI, persists for more than 2 weeks, or recurs within 4 months, a medical
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evaluation is recommended.
The safety of nonprescription antisecretory medications, when used appropriately, is well established. The most common
short-term side effects of PPIs are similar to those reported for the H2RAs (i.e., diarrhea, constipation, and headache).18
Chronic acid suppression has the potential to impair natural defenses and to increase the risk of infection.24-28 Some studies
indicate PPI users may have increased susceptibility to community-acquired pneumonia.8,25 An association of PPI use with
enteric infections, such as Clostridium difficile and bacterial gastroenteritis, has been shown to be statistically significant in a
number of cohort and case control studies. Patients developing diarrhea or symptoms of gastroenteritis while on a PPI should
stop use and contact a health care provider.
An increased risk for hip, spine, and wrist fractures in older patients (>50 years) has been associated with high-dose, long-term
(>1 year) PPI therapy.29 Although reduced gastric acid secretion may decrease calcium absorption, longitudinal studies have
not found any evidence of a direct effect of PPIs on bone turnover.30 FDA released a warning concerning the potential for
increased risk of fractures with prescription PPIs but subsequently determined that the risk is low with appropriate
nonprescription PPI use.31
Rebound acid hypersecretion upon discontinuation of long-term use of PPIs has been reported, but its clinical importance is
uncertain.32 Vitamin B12 deficiency, hypomagnesemia, and iron malabsorption have also been described in patients taking PPIs
long term (usually >1 year) but not in ambulatory patients taking recommended dosages of nonprescription PPIs short
term.24,26,33 Self-treatment with PPIs should be limited to short-term use at nonprescription doses. Nonprescription PPIs should
be used to treat only conditions approved by FDA and listed on the product label. Long-term use and ingestion of high doses of
acid-suppressing medications should take place only under medical supervision.
Omeprazole, esomeprazole, and lansoprazole may inhibit the metabolism of medications that depend on hepatic CYP2C19 for
metabolism.34 Although clinically important drug interactions are uncommon, given the widespread use of PPIs, patients taking
medications such as diazepam, phenytoin, warfarin, theophylline, or tacrolimus should be warned about the potential for a drug
interaction. Omeprazole and esomeprazole appear to have the greatest potential of the nonprescription PPIs to reduce the
antiplatelet effect of clopidogrel by inhibiting variants of CYP2C19, thus reducing the conversion of clopidogrel to its active
form.34,35 Patients taking clopidogrel should contact their cardiologist or primary care provider before taking a nonprescription
PPI (especially omeprazole or esomeprazole). Omeprazole and esomeprazole have been shown to inhibit the metabolism of
cilostazol, resulting in increased serum concentrations of cilostazol and its active metabolites.36 Lansoprazole may be a safer
option for self-treatment of frequent heartburn in patients taking cilostazol. Similar to the action of antacids and H2RAs, PPIs
increase intragastric pH and may decrease the absorption of pH-dependent drugs (see previous discussion of drug-drug
interactions for antacids and H2RAs). PPIs can interfere with elimination of methotrexate and its metabolite,
hydroxymethotrexate, leading to increased risk for toxicity. Patients taking methotrexate should check with their primary care
provider before using a PPI.37,38 In addition, PPIs may increase the bioavailability of digoxin, but the clinical importance of this
effect is unknown. 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.
Bismuth Subsalicylate
Bismuth subsalicylate (BSS) is indicated for heartburn, upset stomach, indigestion, nausea, and diarrhea. FDA has tentatively
determined that BSS is safe and effective for the relief of upset stomach associated with belching and for gas associated with
overindulgence in food and drink.39 It is uncertain how BSS relieves heartburn, but for upset stomach, it is believed to have a
topical effect on the stomach mucosa. When used to treat acid-related symptoms, the adult dose of BSS is 262-525 mg every
30 minutes to 1 hour as needed (Table 13-4). BSS is generally not recommended for children and should be avoided in patients
with renal failure. In the past, some nonprescription antacid product line extensions with common trade names were
reformulated to contain BSS in place of an antacid, or vice versa. Patients and health care providers should examine the
ingredients in an antacid product to determine whether it contains BSS because these products are periodically reformulated
with different antacids and other ingredients. Individuals taking bismuth salts should know that bismuth may cause the stool and
tongue to turn black. Dark-colored stools may be interpreted as an upper GI bleed, prompting needless medical procedures.
(For a complete discussion of BSS, see Chapter 16.)
Product Selection Guidelines
Special Populations
Careful consideration should be given to the elderly before recommending self-treatment for new-onset heartburn or dyspepsia.
Older patients are more likely to take medications that can contribute to heartburn and dyspepsia. In addition, they are at higher
risk for developing complications and may have a more severe underlying disorder. If self-treatment is appropriate, an
assessment should be performed to determine whether the individual has renal impairment and to identify potentially
problematic medications. Patients with decreased renal function should be cautioned about using aluminum- and magnesium-
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containing antacids, and if an H2RA is appropriate, the lower dose should be selected. Omeprazole, esomeprazole, and
lansoprazole may be used in patients with renal impairment. Sodium bicarbonate should be avoided in patients taking
cardiovascular medications.
Antacid selection for eligible patients should be based, in part, on potential side effects. For example, if a patient has a tendency
toward constipation, a less-constipating antacid, such as magnesium hydroxide, may be more appropriate, whereas constipating
antacids, such as aluminum hydroxide, should be avoided.
Children older than 2 years with mild, transient, and infrequent heartburn; acid indigestion; or sour stomach may try childrens
formulas of calcium carbonate-containing antacids. If symptoms recur or are not resolved quickly, the child should be referred to
his or her primary care provider for further evaluation.40 Nonprescription antacids containing calcium carbonate are labeled for
children ages 2 years and older. If antacids are recommended, an assessment of the childs average daily intake of calcium may
help guide the recommendation. The recommended daily intake of calcium for children ages 2-3 years is 700 mg, 4-8 years is
1000 mg, and 9-18 years is 1300 mg.15 Nonprescription H2RAs are labeled for patients ages 12 years and older, and
nonprescription PPIs are indicated for patients ages 18 years or older.
Infrequent and mild heartburn in pregnant women should be treated initially with dietary and lifestyle modifications.41 Calcium-
and magnesium-containing antacids may be used safely if the recommended daily dosages are not exceeded. Special attention
should be given to the recommended intake of calcium during pregnancy (1000-1300 mg/day).15 If a woman is meeting this
recommendation, the addition of a calcium-containing antacid may cause her to exceed the upper limit of 2500 mg of calcium
per day. Cimetidine, ranitidine, and nizatidine are listed as compatible with pregnancy. Human data for omeprazole and
esomeprazole suggest low risk with pregnancy. Famotidine and esomeprazole have limited or no human data to support use in
pregnancy; however, animal data suggest low risk.32 Pregnant women with frequent and moderate-severe heartburn should be
referred for medical evaluation.
Aluminum-, calcium-, or magnesium-containing antacids are considered safe in women who are breast-feeding.42 The American
Academy of Pediatrics considers cimetidine to be compatible with breast-feeding. However, famotidine is less concentrated in
the breast milk and may be preferable to cimetidine or ranitidine.43 There is insufficient information regarding the use of
omeprazole, esomeprazole, and lansoprazole in women who are breast-feeding; these medications are best avoided during
lactation.43
Patient Preferences
Antacids and antisecretory drugs are available in a wide range of prices, flavors, and dosage forms. Once the most appropriate
nonprescription medication is determined, the individual should be involved in selecting a product that is affordable, palatable,
and practical to administer. Inactive ingredients such as dyes, sodium, and sugar should be considered for individuals with
allergies, sensitivities, certain medical conditions, or dietary restrictions.
Complementary Therapies
No evidence has shown that any botanical products increase intragastric pH and relieve heartburn. However, peppermint, alone
or in combination with other herbs, has been shown in some studies to be useful for dyspepsia. A study of the efficacy of
artichoke leaf extract (ALE) for dyspepsia also showed greater improvement of symptoms in the ALE group compared with
placebo.5 (See Chapter 51 for a more thorough discussion of complementary therapies.)
Assessment of Heartburn and Dyspepsia: A Case-Based Approach
Cases 13-1 and 13-2 illustrate the assessment of patients with heartburn and dyspepsia.
Patient Counseling for Heartburn and Dyspepsia
Many cases of uncomplicated heartburn and dyspepsia are self-treatable. For optimal outcomes, individuals need to understand
how to treat symptoms appropriately and when to seek additional care. This information is provided in the box Patient Education
for Heartburn and Dyspepsia. Health care providers should screen patients for use of a prescription H2RA or PPI and counsel
patients to avoid duplication of therapies.
Case 13-1
Relevant Evaluation Criteria Scenario/Model Outcome
Information Gathering
1. Gather essential information about the patients
13 of 22 3/15/2015 1:19 AM
symptoms and medical history, including:
a. description of symptom(s) (i.e., nature, onset, Patient complains of recurring substernal burning sensation after eating
duration, severity, associated symptoms) large meals. It occurs one to two times a week. The discomfort is rated a
4 on a scale of 1-10. It is associated with a feeling of fullness and
occasional burping. Symptoms typically last 3-4 hours after eating.
b. description of any factors that seem to Symptoms occur after eating dinner and are often associated with large
precipitate, exacerbate, and/or relieve the patients meals at restaurants.
symptom(s)
c. description of the patients efforts to relieve the Patient has tried Tums (calcium carbonate 500 mg) after meals to help
symptoms relieve the symptoms. It works initially, but wears off after an hour and
the discomfort returns.
d. patients identity Steve Lee
e. age, sex, height, and weight 55 years old, male, 5 ft 11 in., 215 lb
f. patients occupation Teacher
g. patients dietary habits Normal balanced diet; drinks one cup of caffeinated coffee every
morning, and 1 ounce of whiskey most evenings with dinner.
h. patients sleep habits Sleeps 7-8 hours a night.
i. concurrent medical conditions, prescription and Hyperlipidemia: atorvastatin 20 mg every morning; post-myocardial
nonprescription medications, and dietary infarction (2 years ago): atenolol 25 mg every morning, clopidogrel 75
supplements mg every morning
j. allergies Sulfamethoxazole
k. history of other adverse reactions to None

medications
Assessment Triage
2. Differentiate patients signs/symptoms and Infrequent postprandial substernal burning is consistent with
correctly identify the patients primary problem(s). uncomplicated heartburn.
3. Identify exclusions for self-treatment (Figure None

13-2).
14 of 22 3/15/2015 1:19 AM
4. Formulate a comprehensive list of therapeutic Options include:

alternatives for the primary problem to determine if (1) Refer Steve to his PCP.
triage to a medical provider is required, and share (2) Recommend lifestyle modifications.
this information with the patient or caregiver. (3) Recommend an OTC antacid or acid-reducing product.
(4) Take no action.
Plan
5. Select an optimal therapeutic alternative to An OTC acid-reducing product should be effective. Patient will consider
address the patients problem, taking into account lifestyle modifications.
patient preferences.
6. Describe the recommended therapeutic Take 20 mg of famotidine 30 minutes prior to meals that may cause
approach to the patient or caregiver. heartburn, or when symptoms occur. See directions in Table 13-5.
7. Explain to the patient or caregiver the rationale Seeing a PCP may not be necessary if adequate relief is experienced
for selecting the recommended therapeutic and symptoms do not become more severe or frequent. An antacid will
approach from the considered therapeutic not provide long-lasting relief. You should not use a PPI without
alternatives. consulting your primary care provider because of a possible interaction
with your clopidogrel.
Patient Education
8. When recommending self-care with

nonprescription medications and/or nondrug
therapy, convey accurate information to the patient
or caregiver:
a. appropriate dose and frequency of See Table 13-5.

administration
b. maximum number of days the therapy should be See the box Patient Education for Heartburn and Dyspepsia
employed
c. product administration procedures See Table 13-5.
d. expected time to onset of relief 30 minutes to 1 hour if used after symptoms occur.
e. degree of relief that can be reasonably expected Complete prevention of symptoms if used prior to meals or complete
relief of symptoms if used after symptom onset.
f. most common side effects Side effects are uncommon. Some patients report headache, diarrhea,
or constipation.
g. side effects that warrant medical intervention Moderate-severe diarrhea or symptoms of gastroenteritis
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should they occur
h. patient options in the event that condition A PCP should be consulted if symptoms are not resolved satisfactorily, if
worsens or persists they increase in frequency or severity, or if alarm symptoms occur
(Figure 13-2).
i. product storage requirements See the box Patient Education for Heartburn and Dyspepsia.
j. specific nondrug measures Eat smaller meals, reduce alcohol intake, and avoid problematic foods.
Consider ways to reduce weight. (See the box Patient Education for
Heartburn and Dyspepsia for other measures.)
Solicit follow-up questions from the patient or May I take an antacid for immediate relief of symptoms?
caregiver.
Answer the patients or caregivers questions. Yes. Taking a product that contains calcium carbonate or magnesium
hydroxide after symptoms occur will provide quick, short-term relief.
These can be taken with famotidine if needed. An alternative would be to
take a combination product that contains both an antacid and an acid
reducer.
Evaluation of Patient Outcome
9. Assess patient response. Ask Steve to call or update you on his response to the famotidine, or call
Steve in a week to evaluate his response.
Key: H2RA = Histamine type 2 receptor antagonist; OTC = over-the-counter; PCP = primary care provider; PPI = proton pump
inhibitor.
Case 13-2
1. Gather essential information about the patients

symptoms and medical history, including:
a. description of symptom(s) (i.e., nature, onset, Patient suffers from ongoing upper abdominal discomfort. Patient
duration, severity, associated symptoms) describes a gnawing pain that causes nausea and fluctuates
throughout the day. Pain rating varies from 4-7 on a scale of 10.
Symptoms started 3 days ago. Some difficulty breathing.
b. description of any factors that seem to precipitate, Discomfort worsens when she walks, especially up and down stairs.
exacerbate, and/or relieve the patients symptom(s) Somewhat better at rest.
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c. description of the patients efforts to relieve the Patient has tried Pepcid Complete (famotidine 10 mg, calcium
symptoms carbonate 800 mg, and magnesium hydroxide 165 mg) as well as
Zantac 150 (ranitidine 150 mg) with no relief.
d. patients identity Angelica Mousa
e. age, sex, height, and weight 62 years old, female, 5 ft 5 in., 165 lb
f. patients occupation Retired
g. patients dietary habits Eats small meals throughout the day.
h. patients sleep habits Averages 6 hours per night.
i. concurrent medical conditions, prescription and Hyperlipidemia: stopped taking atorvastatin 1 year ago because she
nonprescription medications, and dietary supplements couldnt afford it. Takes calcium carbonate 1000 mg with vitamin D
400 IU twice daily.
j. allergies NKDA
k. history of other adverse reactions to medications None
l. other (describe) _____ Smokes 15-20 cigarettes/day for the past 40 years. Drinks 2-4 cups
of caffeinated coffee daily. Stopped drinking alcohol 5 years ago.
Assessment and Triage
2. Differentiate patients signs/symptoms and correctly Late-onset and ongoing GI symptoms; worsening upon exertion. No
identify the patients primary problem(s). response to antacid and H2RAs.
3. Identify exclusions for self-treatment (Figure 13-2). May be an indication of cardiac problems, or other non-GI issues.
Alarm symptoms indicate medical referral.
4. Formulate a comprehensive list of therapeutic Options include:

alternatives for the primary problem to determine if (1) Refer Angelica to a PCP immediately for a differential diagnosis.
triage to a medical provider is required, and share this (2) Recommend an OTC product with lifestyle modifications.
information with the patient or caregiver. (3) Take no action.
Plan
5. Select an optimal therapeutic alternative to address Refer the patient to a PCP for a differential diagnosis.
the patients problem, taking into account patient
preferences.
17 of 22 3/15/2015 1:19 AM
6. Describe the recommended therapeutic approach to Call your primary care provider immediately or go to urgent care for
the patient or caregiver. a medical evaluation.
7. Explain to the patient or caregiver the rationale for You need to see your primary care provider because your
selecting the recommended therapeutic approach from symptoms indicate a more serious medical condition that needs
the considered therapeutic alternatives. prompt evaluation. OTC therapy is unlikely to be effective or
appropriate.
8. When recommending self-care with nonprescription Criterion does not apply in this case.
medications and/or nondrug therapy, convey accurate
information to the patient or caregiver.
Solicit follow-up questions from the patient or I thought heart attacks involved a crushing chest pain, so I am not
caregiver. having a heart attack, right?
Answer the patients or caregivers questions. In women heart attacks often present with upper abdominal pain,
nausea, shortness of breath, and other symptoms such as jaw, arm
or shoulder pain. Your symptoms could be from heart disease and
should be medically evaluated as soon as possible.
Evaluation of Patient Outcome
9. Assess patient response. Contact Angelica in a day or two to ensure that she sought medical
care.
Key: H2RA = Histamine type 2 receptor antagonist; NKDA = no known drug allergies; OTC = over-the-counter; PCP = primary
care provider.
Patient Education for Heartburn and Dyspepsia

Heartburn and dyspepsia (indigestion) are often self-treatable conditions. Heartburn is characterized by a burning sensation in
the chest, usually occurring after meals. Dyspepsia is characterized by discomfort in the upper abdomen. The goals of
self-treatment are to (1) provide complete relief of symptoms, (2) reduce recurrence of symptoms, and (3) prevent and manage
unwanted effects of medications.
Nondrug Measures
Avoid food, beverages, and activities that may precipitate or increase the frequency and severity of symptoms.
If possible, avoid the use of medications that may aggravate heartburn or dyspepsia.
Avoid eating large meals.
Stop or reduce smoking.
Lose weight if overweight and not pregnant.
Wear loose-fitting clothing.
If nocturnal symptoms are present:
Avoid lying down within 3 hours of a meal.
Elevate the head of the bed using 6- to 8-inch blocks, or use a foam pillow wedge.
Nonprescription Medications
Store all medications at 68F-77F (20C-25C), and protect them from heat, humidity, and moisture. Discard after
expiration date.
18 of 22 3/15/2015 1:19 AM
Antacids
Antacids (sodium bicarbonate, calcium carbonate, magnesium hydroxide, and aluminum hydroxide) are available alone
and in combination with each other and other ingredients.
Antacids work by neutralizing acid in the stomach.
Antacids may be used for relief of mild, infrequent heartburn or dyspepsia (indigestion).
Antacids are usually taken at the onset of symptoms. Relief of symptoms typically begins within 5 minutes.
Because antacids come in a variety of strengths and concentrations, it is essential to consult the label of an individual
product for the correct dose and frequency of administration. Generally antacids should not be used more than 4 times a
day, or regularly for more than 2 weeks.
If symptoms are not relieved with recommended dosages, consult a health care provider.
Diarrhea may occur with magnesium- or magnesium/aluminum-containing antacids; constipation may occur with
aluminum- or calcium-containing antacids. Consult a health care provider if these effects are troublesome or do not
resolve in a few days.
In children older than 2 years, mild transient and infrequent heartburn; acid indigestion; or sour stomach may be treated
with childrens products containing calcium carbonate if they are used according to package directions.
Pregnant women with mild and infrequent heartburn may use calcium- and magnesium-containing antacids safely if
recommended daily dosages are not exceeded.
Patients with kidney dysfunction should consult their primary care provider prior to self-treatment with antacids.
Patients taking tetracyclines, fluoroquinolones, azithromycin, digoxin, ketoconazole, itraconazole, and iron supplements
should not take antacids within 2 hours of taking any of these medications.
Histamine Type 2 Receptor Antagonists (H2Ras)
H 2RAs (cimetidine, famotidine, and ranitidine) may be used to relieve symptoms of or prevent heartburn and indigestion
associated with meals.
H 2RAs work by decreasing acid production in the stomach.
H 2RAs are usually taken at the onset of symptoms or 30 minutes to 1 hour before symptoms are expected. Relief of
symptoms can be expected to begin within 30-45 minutes. A combination product that contains both an antacid and an
H 2RA provides faster relief of symptoms.
H 2RAs generally relieve symptoms for 4-10 hours. H2RAs can be taken when needed up to twice daily for 2 weeks.
H 2RAs should be used for relief of mild-moderate, infrequent, and episodic heartburn and indigestion when a longer
effect is needed. Use lower dosages for mild infrequent heartburn and higher dosages for moderate infrequent
symptoms.
If symptoms are not relieved with recommended doses, worsen, or persist after 2 weeks of treatment, consult a primary
care provider.
Side effects are uncommon. Consult a primary care provider if side effects are troublesome or do not resolve within a
few days.
Cimetidine may interact with many medications. Consult your primary care provider if you are also taking other
medications, including a blood thinner such as warfarin or clopidogrel, an antifungal such as ketoconazole, an
anticonvulsant such as phenytoin, an antianxiety medication such as diazepam, or theophylline and amiodarone.
Proton Pump Inhibitors (Ppis)
Nonprescription PPIs are indicated for mild-moderate frequent heartburn that occurs 2 or more days a week. They are
not intended for the relief of mild, occasional heartburn.
PPIs (omeprazole, esomeprazole, and lansoprazole) work by decreasing acid production in the stomach.
PPIs should be taken with a glass of water every morning 30 minutes before breakfast for 14 days. Make sure that you
take the full 14-day course of treatment.
Do not take more than 1 tablet a day.
Complete resolution of symptoms should be noted within 4 days of initiating treatment.
If symptoms persist, worsen, are not adequately relieved after 2 weeks of treatment, or recur before 4 months has
elapsed since treatment, consult your primary care provider.
Do not crush or chew tablets or capsules because this may decrease the effectiveness of the PPI.
Side effects are uncommon. Consult a health care provider if side effects are troublesome or do not resolve within a few
days.
Consult a health care provider if you are also taking other medications, including a blood thinner such as warfarin or
clopidogrel, an antifungal such as ketoconazole, an anticonvulsant such as phenytoin, an antianxiety medication such as
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diazepam, antiretroviral medications, methotrexate, theophylline, tacrolimus, digoxin, or cilostazol.
When to Seek Medical Attention

Consult your primary care provider if you experience any of the following:
Heartburn or dyspepsia (indigestion) for more than 3 months

Heartburn or dyspepsia (indigestion) while taking recommended dosages of nonprescription medications
Heartburn or dyspepsia (indigestion) after 2 weeks of continuous treatment with a nonprescription medication
Heartburn that awakens you during the night.
Difficulty or pain on swallowing foods.
Light-headedness, sweating, and dizziness accompanied by vomiting of blood or black material or black tarry
bowel movements.
Chest pain or shoulder, arm, or neck pain, with shortness of breath.
Chronic hoarseness, cough, choking, or wheezing.
Unexplained weight loss.
Continuous nausea, vomiting, or diarrhea.
Severe stomach pain.
Evaluation of Patient Outcomes for Heartburn and Dyspepsia
Individuals taking antacids or an H2RA for infrequent heartburn and dyspepsia should obtain symptomatic relief within 30
minutes to 1 hour. Patients taking PPIs may require up to 4 days for complete relief of symptoms, but most individuals are
asymptomatic within 1 or 2 days. Self-treating individuals should be encouraged to contact their primary care provider to report
on the effectiveness of therapy and on any problems, such as side effects, that may arise during treatment. In some cases, the
provider may make a follow-up contact to assess therapeutic outcomes. Patients should be asked to describe the change in
frequency and severity of symptoms following initiation of therapy. Patients should be questioned regarding side effects and any
new symptoms that may have developed. If the patient reports an inadequate response to therapy, the individual should be
reevaluated to determine whether a different therapy is suitable or whether medical referral is necessary. Side effects may be
managed by adjusting the dose or switching to another product. Patients who develop atypical or alarm symptoms (Figure 13-2)
should be referred to their primary care provider.
Key Points for Heartburn and Dyspepsia
The self-treatment of heartburn and dyspepsia should be limited to mild or moderate symptoms, including postprandial
burning in the upper abdomen or centralized abdominal discomfort.
Patients with atypical or alarm symptoms (Figure 13-2) should be referred for further evaluation.
In children older than 2 years, treatment of mild transient and infrequent heartburn, acid indigestion, or sour stomach
symptoms with calcium carbonate-containing antacids should be limited; prompt referral should be made if symptoms
recur or persist.
Pregnant women may self-treat mild and infrequent heartburn with calcium- and magnesium-containing antacids.
Patients with heartburn should be counseled on nondrug measures such as dietary and lifestyle modifications (see the
box Patient Education for Heartburn and Dyspepsia).
Self-treating individuals should be advised about the advantages and disadvantages of various antacids and
acid-reducing products so they can select a product that is best suited to them.
Antacids provide temporary relief for mild and infrequent heartburn and dyspepsia. Dosages are product specific
because of variability in antacid ingredients and concentrations.
H 2RAs are indicated for mild and infrequent heartburn or dyspepsia. They may be taken at the onset of symptoms or 1
hour prior to an event (e.g., meal or exercise) that may cause symptoms.
Combining an antacid with an H2RA provides immediate relief of heartburn and a longer duration of action.
PPIs are indicated for the treatment of frequent heartburn (heartburn that occurs 2 days a week). PPIs should be used
a maximum of 14 days at a time and no more than every 4 months, and they are not intended for immediate relief of
infrequent symptoms.
Individuals with self-treatable symptoms should be advised to contact their primary care provider if symptoms worsen or
recur after 14 days of effective self-treatment.
References
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in symptomatic GERD patients. Aliment Pharmacol Ther. 2011;34(1):59-66. PubMed
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issues and proposed guidelines. Digestion. 2009;80(4):226-34.
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Accessed at http://dietary-supplements.info.nih.gov/factsheets/calcium.asp, April 24, 2013.
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2015 American Pharmacists Association. All Rights Reserved.
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Handbook of Nonprescription Drugs > Chapter 13. Heartburn and Dyspepsia

Heartburn and Dyspepsia: Introduction

Esophageal defense mechanisms and offensive factors associated with heartburn.

Alcohol (ethanol) Alpha-adrenergic antagonists

Caffeinated beverages Anticholinergic agents

Carbonated beverages Aspirin/NSAIDs

Citrus fruit or juices Benzodiazepines

Coffee Beta2-adrenergic agonists

Fatty foods Bisphosphonates

Garlic or onions Calcium channel blockers

Mint (e.g., spearmint, peppermint) Chemotherapy

Salt and salt substitutes Clindamycin

Spicy foods Dopamine

Tomatoes/tomato juice Doxycycline

Exercise (isometric, running) Narcotic analgesics

Smoking (tobacco) Potassium

Supine body position Prostaglandins

Tight-fitting clothing Quinidine

Motility disorders (e.g., gastroparesis) Tetracycline

Zollinger-Ellison syndrome Other

Source: References 1, and 6-8.

Simple Heartburn GERD Dyspepsia PUD

Simple Heartburn GERD Dyspepsia PUD

Treatment of Heartburn and Dyspepsia

General Treatment Approach

Medication Onset of Relief Duration of Relief

Antacids <5 minutes 20-30 minutesa

H2RAs 30-45 minutes 4-10 hours

H2RA + antacid <5 minutes 8-10 hours

PPIs 2-3 hours 12-24 hours

a Food prolongs duration of relief.

Trade Name Primary Ingredients Dosage (maximum daily dosage)

Relief Chewable Age 6-11 years: 2 tablets (6 tablets)

Age 6-11 years: 2 tablets (6 tablets)

a Sodium alginate (alginic acid) is listed as an inactive ingredient.

Histamine Type 2 Receptor Antagonists

Trade Name Primary Ingredients Dosage (maximum daily dosage)

H2RA Products (Adults/Children 12 Years)

Pepcid AC, various Famotidine 10 mg 1 tablet with a glass of water (2 tablets)

Pepcid AC Maximum Famotidine 20 mg 1 tablet with a glass of water (2 tablets)

Trade Name Primary Ingredients Dosage (maximum daily dosage)

H2RA Products (Adults/Children 12 Years)

PPI Products (Adults 18 Years)

Nexium 24HR Esomeprazole 20 mg 1 capsule with a glass of water 30 minutes before

Proton Pump Inhibitors

Product Selection Guidelines

Assessment of Heartburn and Dyspepsia: A Case-Based Approach

Patient Counseling for Heartburn and Dyspepsia

Relevant Evaluation Criteria Scenario/Model Outcome

1. Gather essential information about the patients

Relevant Evaluation Criteria Scenario/Model Outcome

symptoms and medical history, including:

d. patients identity Steve Lee

f. patients occupation Teacher

h. patients sleep habits Sleeps 7-8 hours a night.

k. history of other adverse reactions to None

3. Identify exclusions for self-treatment (Figure None

Relevant Evaluation Criteria Scenario/Model Outcome