Acid-suppressive therapy is the mainstay of treatment for gastroesophageal reflux disease (GERD). Antacids, histamine2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) can be used in patients with GERD. Prokinetic agents are of limited utility due to inadequate efficacy and poor tolerability.
Antacids rapidly neutralize gastric acid but have a short duration of action and high potential for drug interactions. They are more effective than placebo in treating heartburn, but evidence is lacking on the effectiveness of antacids in treating reflux esophagitis. Most antacids contain aluminum, calcium, or magnesium salts. Side effects of antacids mostly involve the GI tract, with dose-limiting diarrhea with magnesium preparations and constipation with aluminum- and calcium-containing products. Caution must be exercised in those with renal insufficiency because of the potential for accumulation and toxicity of magnesium and aluminum. Some antacid preparations contain alginic acid, which may prevent reflux by forming a barrier on top of gastric contents.
Compared to antacids, OTC (over-the-counter) H2RAs–cimetidine (Tagamet HB), famotidine (Pepcid AC), ranitidine (Zantac 75), and nizatidine (Axid AR)–have a longer duration of action but slower onset of action. Nonprescription doses of H2RAs are effective in preventing and treating meal-related heartburn but have no effect on the healing of esophagitis.
Recently, the FDA approved omeprazole 20 mg for OTC use (Prilosec OTC). Prilosec OTC is the first OTC (over-the-counter) agent available for treatment of frequent heartburn, defined as heartburn that occurs on more than two days a week. Prilosec OTC is approved for a 14-day treatment course that should not be repeated more frequently than every four months. It is important to note that Prilosec OTC is not approved for the treatment of heartburn associated with gastroesophageal reflux disease (GERD). Omeprazole 20 mg will still be available by prescription for the treatment of GERD symptoms and esophagitis. Due to the serious nature of GERD complications, patients complaining of frequent, persistent heartburn associated with gastroesophageal reflux disease (GERD) should not self-manage their disease with OTC (over-the-counter) therapy and should seek medical follow-up.