Thankfully, there are several options available for managing acid reflux disease. The options can be viewed as a progressively more complex management approach that begins solely with diet and lifestyle adjustments, then adds medications and, under certain specific circumstances, utilizes surgery. Complementary and alternative medicine approaches may also be helpful in some cases. There are many choices because management decisions for acid reflux disease are typically based not only on a person’s general health, but also ultimately on their particular desires.
While diet and lifestyle changes are necessary to most effectively manage acid reflux disease, medications play a key role in managing the condition in many people. Since numerous previously prescription-only medications are now accessible over the counter, it is very important (now more than ever) to be aware of the choices available. As acid is the main culprit in acid reflux disease, the primary approaches to drug therapy are to either neutralize the acid with an alkaline substance or reduce the amount of acid produced by the stomach.
Although many of these drugs are available without a prescription, they all have potential side effects and can interact with other medications. Because of this, obtain approval from your doctor before beginning any of these medications.
The acid-neutralizing drugs — also called antacids — are all available without a prescription. The most common are minerals like calcium, magnesium or aluminum combined with hydroxide, carbonate or bicarbonate to form an alkaline solution that neutralizes stomach acids. Some over-the-counter preparations add other drugs as well, such as simethicone, which dissolves gas bubbles, or anti-inflammatory drugs like aspirin. Several of the most popular antacids are calcium carbonate (Tums); magnesium hydroxide, aluminum hydroxide and simethicone (Mylanta); magnesium hydroxide and aluminum hydroxide (Maalox); calcium carbonate and magnesium hydroxide (Rolaids); and sodium bicarbonate, aspirin and citric acid (Alka Seltzer).
Antacids act within minutes and last for about one hour to neutralize the acidity of stomach acid. Although often helpful, about one in four people do not get relief from these medications, according to a 2013 article in Gastroenterology Research and Practice.
Acid Neutralizer Side Effects and Interactions
The most common side effects of acid neutralizers are constipation if they contain calcium or aluminum, and diarrhea if they contain magnesium. To balance these effects, some preparations contain calcium or aluminum combined with magnesium. Antacids may also cause changes in the levels of calcium, magnesium, bicarbonate and sodium in the blood, especially if they are taken in large quantities on a regular basis.
When antacids are taken at about the same time as some other medications, they may affect the absorption of these drugs into the body. Some antacids can directly bind to certain drugs, reducing their absorption. Furthermore, the increase in pH produced by antacids can either decrease or increase the absorption of other medications.
There are two classes of acid reducers: histamine 2 receptor antagonists (also known as H2RAs or H2-blockers) and proton pump inhibitors (PPIs). Both classes are much more powerful at combating acid than the neutralizers, and their effects last considerably longer as well.
H2-blockers act by preventing histamine from attaching to special proteins called histamine 2 receptors on acid-producing cells in the stomach. Since histamine attaching to the receptors causes acid production, blocking the attachment suppresses acid production, generally for up to eight hours. Cimetidine (Tagamet), nizatidine (Axid), famotidine (Pepcid) and ranitidine (Zantac) are common H2-blockers. While they are very good acid-reducing medications, H2-blockers are not as effective as PPIs, especially for the treatment of the most severe forms of esophageal inflammation caused by gastroesophageal reflux disease, or GERD.
Proton Pump Inhibitors
PPIs are the most powerful class of acid-reducing medications. According to a study in the World Journal of Gastroenterology, PPIs are more effective than H2-blockers in healing all degrees of esophageal inflammation, whether it is mild, moderate or severe. PPIs act by directly blocking the production of acid in stomach cells.
Common PPIs include esomeprazole (Nexium), omeprazole (Prilosec), lansoprazole (Prevacid), pantoprazole (Protonix) and rabeprazole (Aciphex). A single dose can suppress stomach acid for up to 18 hours. PPIs are finicky in that to be most effective they should be taken 30 to 60 minutes before meals.
According to guidelines published by the American College of Gastroenterology in 2013, proton pump inhibitors — medications that reduce acid production — are the first-choice medications for most people with acid reflux disease.
Acid Reducer Side Effects and Interactions
Acid-reducing medications are usually well tolerated and have a low likelihood of causing serious problems. Headaches are the most common side effect, occurring in less than 10 percent of people. Allergic reactions may occur with acid-reducing medications, but they are uncommon. Long-term use of these medications, especially PPIs, may increase the likelihood of developing vitamin B-12 deficiency, fractures due to osteoporosis, gastrointestinal tract infections and pneumonia.
Like antacids, the increase in stomach pH caused by acid reducers can increase or decrease the absorption of some other medications taken by mouth. Both PPIs and H2-blockers can affect the ability of the liver to break down certain drugs. For example, they can impair the breakdown of the blood thinner warfarin, which may increase the risk of bleeding unless the warfarin dose is decreased. Conversely, PPIs can reduce the effectiveness of another blood-thinner clopidogrel (Plavix).
Other Drugs for Acid Reflux
Another class of medications, called motility agents, is sometimes used to treat GERD. Metoclopramide (Reglan) is the only drug of this class currently available in the United States. Motility agents act by increasing the strength of the LES, improving esophageal motility and increasing emptying of the stomach. Although they used to be commonly prescribed for acid reflux disease, motility agents have now been mostly replaced by the more effective PPIs. They may still be used in combination with PPIs in some individuals if treatment with PPIs alone is not adequate. Motility agents have a number of side effects, such as drowsiness, irritability and agitation, which have contributed to their decreased use.
Medications and Laryngopharyngeal Reflux Disease
Although PPI therapy is very helpful for GERD, it may be less effective for LPRD. This occurs because in some people with LPRD, other factors play a more prominent role in causing symptoms than acid refluxed from the stomach. In these individuals, pepsin — a protein found in the tissues affected by LPRD — and acidic food as it is being swallowed are major causes of inflammation and symptoms. Nevertheless, PPI therapy remains effective in a large number of people with LPRD. A study published in April 2015 in the Journal of Clinical Gastroenterology compiled the results of 14 previous studies and concluded that PPIs produced significant improvements in LPRD symptoms, especially hoarseness.
While most people are able to control their symptoms with nonsurgical methods, these approaches do not always produce adequate relief. There are various surgical options for treating GERD, almost all of which involve methods to tighten the LES and thereby reduce the amount of material coming up from the stomach.
There are two types of surgical options generally used: endoscopic and laparoscopic techniques. The endoscopic methods involve the use an endoscope and other instruments to reach the LES from inside the esophagus. They are typically performed while the person receives deep sedation. Although there are several types of endoscopic procedures, they all involve making the LES smaller or tighter. One of the newer methods involves the insertion of fasteners made of polypropylene — a durable, waterproof and flexible plastic — that pull the sides of the LES closer together.
According to a study published in the October 2013 issue of Surgical Endoscopy, this appears to be a very effective technique, but no long-term studies have been performed to assess its usefulness over a prolonged time period. Another endoscopic technique involves applying radio frequency energy to the LES, which increases LES tightness, in part by promoting the growth of more LES muscle cells. In a study reported in the August 2014 issue of Surgical Endoscopy, this technique produced long-term improvement of GERD symptoms.
The laparoscopic techniques approach the LES from the outside, with tubes and instruments being inserted into the abdomen through a number of small incisions. These methods require full general anesthesia. During laparoscopic procedures, a portion of the stomach is wrapped around the LES, thereby tightening it. Stomach-wrapping techniques are often more effective than medications alone in controlling GERD symptoms for a prolonged period of time.
A newer laparoscopic technique using titanium beads to surround the LES was noted to be effective in a study of 44 adults reported in the October 2012 issue of Surgical Endoscopy, but larger and longer-term studies are needed to determine whether it will be useful for prolonged control of acid reflux symptoms.
- American College of Gastroenterology: Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease.
- Killing Me Softly From Inside - The Mysteries and Dangers of Acid Reflux and Its Connection to America’s Fastest Growing Cancer with a Diet That May Save Your Life; Jonathan E Aviv, MD FACS.
- The American Journal of Gastroenterology: Management Strategy for Patients with Gastroesophageal Reflux Disease - A Comparison Between Empirical Treatment with Esomeprazole and Endoscopy-Oriented Treatment
- Surgical Endoscopy: Effect of Transoral Incisionless Fundoplication on Reflux Mechanisms.
- Therapeutic Advances in Gastroenterology: LINX(®) Reflux Management System in Chronic Gastroesophageal Reflux - A Novel Effective Technology for Restoring the Natural Barrier to Reflux.
- Cochrane Database of Systematic Reviews: Medical versus Surgical Management for Gastro-Oesophageal Reflux Disease (GORD) in Adults
- Surgical Endoscopy: The LINX® Reflux Management System: Confirmed Safety and Efficacy Now at 4 years
- Surgical Endoscopy: Impact of Transoral Incisionless Fundoplication (TIF) on Subjective and Objective GERD Indices - A Systematic Review of the Published Literature.
- Surgical Endoscopy: Long-Term Maintenance Effect of Radiofrequency Energy Delivery for Refractory GERD - A Decade Later.
- Alimentary Pharmacology and Therapeutics: Effects of Antacid Formulation on Postprandial Oesophageal Acidity in Patients with a History of Episodic Heartburn.