Almost everyone has heartburn once in a while—for example, after a heavy or spicy meal, or after drinking alcohol. Heartburn is an uncomfortable sensation that usually starts just below your breastbone and can radiate into your throat. You may also get a sour or bitter taste in your mouth or throat.
Occasional heartburn is not worrisome or dangerous, and can be largely relieved by taking over-the-counter antacids or H2 blockers. Even if you have a period of time—say a couple of weeks—in which you get heartburn fairly regularly, you may not need anything stronger than those drugs.
However, if you have heartburn at least twice a week for weeks or months on end, have frequent regurgitation of food into your throat or mouth (with or without heartburn), or if your heartburn is not relieved by antacids or H2 blockers, you may have gastroesophogeal reflux disease (GERD).
In contrast to occasional heartburn, GERD can be dangerous. If it isn’t treated, over time, the acid reflux can inflame or erode the lining of the esophagus, a condition called esophagitis. You may sense it as a chronic soreness in your lower throat and/or chest. Most cases of esophagitis are relatively mild. But if left untreated, it can result in bleeding, scarring, and a narrowing of the esophagus. This can make eating and swallowing foods painful and difficult. People who have uncontrolled GERD for years also have a higher risk of cancer of the esophagus, though this cancer is rare.
GERD (gastroesophageal reflux disease) is not just the result of frequent heartburn or excessive eating, as commonly thought. It’s caused by a physical condition that many people appear prone to, when the ring of muscle between the esophagus and stomach doesn’t work properly. The muscle usually opens when food is passing through on its way to the stomach. In people with GERD, however, the muscle seems to open at other times. Or it stays open too long after food has passed through. When either happens, acid from the stomach can flow back up into the esophagus. This is called acid reflux.
Heartburn and GERD are quite common. Heartburn is the main symptom of GERD but does not always signal it. Between a quarter and a third of adults in the U.S. will have GERD symptoms at some point. It is most common among people ages 50 and older but can strike at any age. Pregnant women are also highly prone to GERD.
Omeprazole OTC (generic of Prilosec OTC)
Lansoprazole OTC (generic of Prevacid 24HR)
Both of these drugs are available without a prescription. You could save $200 a month or more by choosing one of these medicines over more expensive prescription PPIs. If you have health insurance, find out if your plan will help pay for generic omeprazole OTC or generic lansoprazole OTC. If not, talk with your doctor about taking the PPI with the lowest out-of-pocket cost for you. If you have esophagitis (inflammation of the esophagus), you might want to consider esomeprazole (Nexium), pantoprazole (Protonix and generic), or rabeprazole (AcipHex). Some research suggests those drugs could provide better healing from esophagitis.
Our choice of these over-the-counter medicines presents two questions, however. The first is: Do you need to visit a doctor if you start taking one of them for heartburn and think you may have GERD? The answer is yes. Buying these drugs to relieve occasional heartburn requires no initial physician visit, saving you that trouble and expense. But if you have persistent heartburn—twice a week for several weeks—or you have soreness in your throat or chest, you should see a doctor as soon as possible, even as you continue to take the over-the-counter PPIs or any other nonprescription acid reducer. Remember, GERD can be dangerous and you can’t diagnose it yourself.
The seven available PPI medicines are roughly equal in effectiveness and safety but differ in cost. Three—omeprazole (Prilosec, Prilosec OTC), lansoprazole (Prevacid, Prevacid 24HR), and omeprazole/sodium bicarbonate (Zegerid, Zegerid OTC)—are available as both prescription and nonprescription drugs. Four—lansoprazole, omeprazole, omeprazole/sodium bicarbonate, and pantoprazole (Protonix)—are available as both brand-name drugs and generics that contain the same active ingredient but cost significantly less.
PPIs work by blocking an enzyme that is necessary for making acid in the stomach. When this enzyme is blocked, acid production decreases.
PPIs are very effective and relatively safe. But not everyone needs one. Several of them have been widely advertised to the public and promoted to physicians— particularly Nexium (the “purple pill”), which earned nearly $6 billion in sales in 2012, making it the top seller among all medications, according to IMS Health. Many physicians think the heavy promotion has led to an overuse of PPIs in the treatment of occasional heartburn. Figures from IMS Health show the number of prescriptions written in the U.S. for PPIs in 2012 topped 127 million, making them among the most commonly prescribed class of drugs.
Before you start taking a PPI, we advise talking with your doctor about other medicines that may be useful if you have only occasional heartburn (once a week or less) and have not been diagnosed with GERD.
PPIs don’t cure GERD; they treat the symptoms. Not a lot is known about how people with GERD do over the long-term. But it appears that some have GERD for life while for most, the condition occurs only sometimes or resolves on its own.
All PPIs are highly effective at reducing stomach acid, relieving heartburn, and thereby helping to heal damage to the esophagus caused by GE RD. The overall evidence from research that compared the drugs with each other shows them to be very similar, with no PPI any better than any other. Some studies have indicated that esomeprazole (Nexium) may have a slight advantage, but the drug was administered at a higher dose in these trials.
As you can see in Table 1, below, if you take a PPI you have a 65 to 77 percent chance of complete symptom relief after four weeks. You have a 77 to 90 percent chance that any damage that occurred to your esophagus will be healed after eight weeks. And the majority of people who are advised to remain on a PPI to prevent relapses don’t usually experience one. Some research indicates pantoprazole and rabeprazole provide better symptom relief and healing of esophagitis at eight weeks, and that esomeprazole provides better esophagus healing (inflammation has gone away) over 6 months.
The figures in Table 1, below, are compiled from many studies, so they do not reflect a direct comparison of the PPI drugs as if the drugs were evaluated against each other in a single study. The figures are presented here to illustrate the general effectiveness of the class of PPIs. The differences between the drugs should not be taken as an indication that one drug is stronger or weaker, or better or worse, than any other. That is one reason we give you the ranges of response as well as the averages.
PPI drugs can cause both minor and serious side effects, but studies have not found any significant differences between the PPIs in the side effects they cause or their safety profiles. Minor side effects include headache and diarrhea. About one to three percent of people stop taking a PPI because they cannot tolerate the side effects. In light of the potential risks, the FDA advises doctors and patients to only use PPIs when necessary and to limit them to the lowest dose for the shortest period required for relief, or that is appropriate for your condition.
One serious side effect of PPIs includes being susceptible to certain infections since there is a decreased production of stomach acid, which normally helps protect against infections by killing bacteria and viruses. Specifically, taking PPIs can increase the risk of community-acquired pneumonia, particularly within the first month of use. They can also increase the risk of infection with a bacterium called Clostridium difficile, which can cause disabling diarrhea and high fever and can lead to more serious intestinal conditions.
You may be at higher risk for infection if you have asthma, lung disease, decreased immunity (because of HIV or AIDS, for example), or are older. People 65 and older are already advised to get vaccinated against pneumonia and to get a flu shot every year. Taking a PPI on a regular basis may be another important reason to get both vaccines.
In addition, several studies have found that some people who took PPIs had a higher risk of hip fractures, and one study found an increased risk of wrist and forearm fractures. The drugs can potentially interfere with the absorption of calcium, which can lead to weakened bones. The bone fractures occurred mostly in patients older than 50 who either took high doses or PPI or stayed on them for one year or longer according to an FDA review.
In addition, when taken for longer than a year, PPIs can lower blood levels of magnesium. Although many patients don’t have symptoms when their magnesium levels are low, it can be a serious condition leading to muscle spasms, irregular heartbeat, and seizures. If you might be on a PPI for a long time or if you are taking digoxin, a diuretic, or any other medication that can lower your magnesium, your doctor should order blood tests to monitor your magnesium levels.
PPIs are known to interact with other medicines and dietary supplements in ways that can be dangerous. In some cases, your doctor may recommend that you take a specific PPI because of evidence that it is less likely to interact with another drug you are taking.
People often take a PPI to decrease stomach irritation and bleeding that can occur with a blood-thinning drug called clopidogrel (Plavix or generic)—often prescribed for patients after heart attacks, strokes, stent placements, and other heart problems. But if you take Plavix, you should be cautious about taking a PPI, particularly esomeprazole or omeprazole because they can reduce Plavix’s protective effect, which could increase the risk of another heart attack. This issue is important to discuss with your doctor if you take clopidogrel. Our medical advisers recommend that people who take Plavix should skip PPIs unless other treatments have not been adequate.
If you take Plavix and require a medication to treat your heartburn, GERD, or gastric ulcer and your symptoms aren’t severe, another option may be an older class of drugs called H2 blockers, which includes nizatidine (Axid, Axid AR), famotidine (Pepcid, Pepcid AC), and ranitidine (Zantac, Zantac 75, Zantac 150). All are available as low-cost generics. You could also try an antacid. These drugs have not been associated with reducing the protective effects of Plavix. You should also talk to your doctor about having periodic blood counts or monitoring of your stools in order to detect gastrointestinal bleeding you may not be aware of (black, tarry stools can be a sign of this, for example).
The main drugs to be concerned about potentially interacting with PPIs are:
Risks with Pregnancy
One study found no increased risk of rates of preterm birth, miscarriage, ectopic pregnancy, or stillbirth in women who took PPIs while pregnant, compared to those who did not. But this study had several limitations, so more studies would be needed to confirm there is no risk before a definitive conclusion can be made.
Finally, studies indicate that about three percent of Caucasians and African-Americans and 17 to 25 percent of Asian-Americans have less than average amounts of the enzymes that break down PPIs in the body. For these groups of people, less than the usual dose of a PPI might work just as well to relieve symptoms, though the usual doses are considered to be safe. Testing to determine a person’s level of this enzyme is not necessary.
If you suffer from occasional heartburn and have not been diagnosed with GERD, nonprescription antacids such as Maalox, Mylanta, Rolaids, and Tums, or acid-reducing drugs known as H2 blockers, such as cimetidine (Tagamet), famotidine (Pepcid), nizatidine (Axid), and ranitidine (Zantac) will very likely provide relief. All of those products are available without a prescription as low-cost generics.
Another class of drugs, called H2 blockers, is also available over-the-counter to treat mild, occasional heartburn and excess stomach acidity. The nonprescription versions of drugs in this class include cimetidine (Tagamet OTC), famotidine (Pepcid AC), nizatidine (Axid AR), and ranitidine (Zantac 75, Zantac 150), all of which are available as low-cost generics. H2 blockers take longer to work than antacids—30 minutes to an hour—but they provide heartburn relief for up to 12 hours.
Stronger doses of H2 blockers are also available by prescription, and all are also available as lower-cost generics.
Talk with your doctor about the role that dietary and lifestyle changes can play in alleviating heartburn, too, such as eating smaller meals and not lying down for at least three hours after eating, losing weight if you need to, and avoiding alcohol. If, however, you experience heartburn twice a week or more for weeks or months on end, have frequent regurgitation of food into your throat or mouth (with or without heartburn), or if your heartburn is not relieved by the drugs mentioned above, you may have GERD and may need a PPI. GERD is a condition that makes you prone to acid reflux and, over time, can cause damage to your esophagus.
Consumer Reports. Proton pump inhibitors (PPI) medicines review. Our review of these drugs shows all are similar but there are big differences in price. Published July 2013.