Guidelines for Taking Over-the-Counter Heartburn Medications

Rosemary R. Berardi, Pharm.D., FCCP, FASHP, FAPHA

What is Heartburn?

Heartburn is the most common symptom of acid reflux, acid indigestion, or gastroesophageal reflux disease (GERD). It is often mild and occasional (episodic), but for some it may be frequent (occurs 2 or more days a week), moderate to severe and long-lasting. For many individuals, heartburn can be controlled by lifestyle and dietary modifications and the proper use of over-the-counter medications.

What Over-the-Counter (OTC) Medications are Available to Treat Heartburn?

Various antacids, H2-receptor antagonists (H2-blockers), such as: famotidine (Pepcid AC®, Pepcid AC Max®, Pepcid Complete®) and ranitidine (Zantac 75®, Zantac 150®), and proton pump inhibitors such as omeprazole (Prilosec OTC ®) are available without a prescription. Antacids partially neutralize stomach acid and are used to relieve mild, infrequent heartburn. The H2-receptor antagonists partially block acid production by inhibiting histamine, one of several chemicals that stimulate acid secretion in the stomach. The lower nonprescription dosages of the H2 blockers (e.g., Pepcid AC®, Zantac 75®) provide a mild degree of acid inhibition. The higher nonprescription dosages of the H2 antagonists (e.g., Pepcid AC Max®, Zantac 150®) are associated with moderate inhibition of stomach acid an may exert their effect for 6 to 10 hours. The OTC proton pump inhibitor (Prilosec OTC®) is available at its former prescription strength and act differently from antacids and H2-blockers. Prilosec OTC ® significantly blocks acid production at its source, targeting the “acid pumps” in the stomach. Nonprescription omeprazole (Prilosec OTC®) is the most powerful acid blocker blocking acid for up to 24 hours with a single dose. Prilosec OTC® is more effective than the H2-receptor antagonists in preventing heartburn.

How do I know which heartburn medication to take?

Antacids, H2-receptor antagonists, and proton pump inhibitors are all effective in controlling heartburn. You must first decide if your goal is to treat or prevent heartburn. If your goal is to treat heartburn, the selection of a product should be based on the onset and duration of symptom relief provided by the medication and the frequency and severity of your heartburn. If you are able to predict when your heartburn will occur (e.g., heartburn brought on by eating or drinking certain foods or beverages), you may wish to use a medication to prevent heartburn.

Antacids - Antacids are typically used to treat mild, occasional heartburn. They provide rapid (within minutes) relief of symptoms, but relief only lasts for about 20 to 30 minutes when taken on an empty stomach. Taking an antacid after a meal prolongs its effect for 2 to 3 hours.
H2-receptor antagonists - H2-receptor antagonists are used to treat mild to moderate, infrequent heartburn. These medications begin to relieve heartburn within an hour and provide a longer duration of relief (6 to 10 hours) when compared to antacids. The lower nonprescription dosages, e.g., Zantac 75®, Pepcid AC®, should be used for mild heartburn, whereas the higher nonprescription dosages, e.g., Zantac 150®, Pepcid AC Max®, should be reserved for more moderate symptoms. An over-the-counter product that contains famotidine and an antacid (Pepcid Complete®) is also available. This medication provides both immediate and 6 to 10 hour relief of heartburn.
Proton pump inhibitors – Nonprescription OTC omeprazole (Prilosec OTC®) is intended for people who suffer from frequent heartburn (2 or more days a week). This medication should not be used to treat mild or occasional heartburn. In contrast to the antacids and the H2-blockers, proton pump inhibitors usually take 2 to 3 hours to begin to relieve your heartburn, but relief often lasts up to 24 hours with once daily dosing. It may take 3 to 4 days for some people to experience the full therapeutic effect of Prilosec OTC®, but many people get complete relief within 24 hours after the first dose.

When should I to take my heartburn medication?

Antacids - Antacids may be taken when needed on an empty stomach or after a meal. The antacid label contains information on how often you can take the medication, the maximum amount that can be taken in 24 hours, and what precautions should be observed to prevent adverse effects. This information will vary for different antacid products. Read the packaging label carefully or ask your doctor or pharmacist before use if you are taking prescription medications or other OTC medications as they may interact with the antacid if taken together.
H2-receptor antagonists - H2-receptor antagonists may be taken at any time when needed to treat heartburn. However, no more than two doses (of either the reduced or higher nonprescription dosages) should be taken in any 24 hour period. Individuals with only daytime heartburn may benefit from taking the medication in the morning whereas those with nighttime heartburn should take the medication in the evening or before bedtime. If it is necessary to take the medication twice daily, it is best to separate the two doses by at least 8 hours. In some individuals, the acid-blocking effect of an H2-receptor antagonist may decrease with continuous daily administration. This may result in decreased effectiveness. Therefore, it is best to take an H2-receptor antagonist on a "when needed basis" if possible, rather than daily for several weeks. When an H2-blocker is used to prevent heartburn, it should be taken 10 to 60 minutes before eating food or drinking beverages that cause heartburn.
Proton pump inhibitors - In contrast to the H2-blockers, nonprescription omeprazole (Prilosce OTC®) should be taken once daily every day for 14 days. You should not take this medication longer than 14 consecutive days without discussing it with your doctor. Proton pump inhibitors work best when the stomach is most actively producing acid, which typically occurs soon after meals. If you take the proton pump inhibitor 30 to 60 minutes before a meal, you will achieve the greatest effect from this drug. If you forget to take the medication prior to the meal, it is best to not skip a dose, so taking with or immediately after the meal is better than not taking it at all. Taking medication in the morning before breakfast is often preferred because most individuals remember to take their medications at this time. You may take this medication before lunch or dinner if your heartburn occurs later in the day or at night, but avoid taking this medication on an empty stomach before bedtime. Prilosec OTC® as a single daily dose provides protection against heartburn for up to 24 hours.

How long should I take my heartburn medication?

Antacids and H2-receptor antagonists should not be taken for longer than 14 days consecutive without the advice of your doctor. Nonprescription omeprazole should not be taken for more than one 14-day course of treatment every four months, unless otherwise directed or approved by your doctor. If you need to take these medications for more than 14 consecutive days or if your heartburn continues or worsens with treatment, you should stop the medication and consult your physician.

Can I take more than one heartburn medication in a day or increase the daily dose if one product dose not provide adequate relief?

Antacids may be taken occasionally, if needed, while taking either an H2-blocker or nonprescription omeprazole. If frequent antacid dosing is necessary, you should contact your physician. You should not take an H2-receptor antagonist while taking a proton pump inhibitor unless you are directed to do so by your physician. Do not self-treat with two different H2-blockers at the same time or increase the daily dosage of any over-the-counter heartburn product above that which is recommended on the package label.

What other tips can you give me about taking heartburn medications?

Medications used to treat heartburn are available in a number of different oral dosage forms, including liquids, tablets, gelcaps, and chewable tablets. Check the package label to determine if tablets should be swallowed whole or chewed before swallowing.
Ask a physician or a pharmacist before use if you are taking a prescription medication that may interact with your heartburn medication.
If pregnant or breastfeeding, you should ask a health professional before using any medication to treat heartburn.
Check the package label for each specific product to determine if the medication can be used in children without consulting a physician. Some medications may be used in children, but the daily dosage will differ from that of an adult.

References:

Fackler WK, Ours TM, Vaezi MF, Richter J, et al. Long-term effect of H2RA therapy on nocturnal gastric acid breakthrough. Gastroenterology 2002;122:625-32.
Furuta K, Adachi K, Komazawa Y, et al. Tolerance to H2 receptor antagonist correlates well with the decline in efficacy against gastroesophageal reflux in patients with gastroesophageal reflux disease. J Gastroenterol Hepatol 2006;21:1581-85.
Hatlebakk JG, Katz PO, Camacho-Lobato L, et al. Proton pump inhibitors: better acid suppression when taken before a meal than without a meal. Aliment Pharmacol Ther 2000;14:1267-72.
Richter JE. Gastroesophageal reflux disease. In: Yamada T, Alpers DH, Kaplowitz N, et al., eds. Textbook of Gastroenterology. 4th ed. Philadelphia: Lippincott Williams & Williams; 2003:1196–1224.
Zweber A, Berardi RR. Heartburn and Dyspepsia. In: Berardi RR, McDermitt JH, Newton GD, et al eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 15th ed. Washington, DC: American Pharmaceutical Association; 2006:265-282.