HelixTalk Episode #45 - Self-care of Heartburn and Dyspepsia

Date posted: June 21, 2016, 6:00 am

In this episode, we discuss self-care of heartburn and dyspepsia, including antacids, bismuth subsalicylate, H2 blockers, and PPIs.

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Key Concepts

1. Patients complaining of any pain, discomfort, or difficulty when swallowing are not appropriate for self care.  Also, patients with any warning signs of heart attack (such as chest pain with shortness of breath, sweating, radiating pain, etc.) should seek emergent medical care.
2. All patients with heartburn should be counseled on non-pharmacologic therapy, including avoidance of trigger foods (including caffeine, carbonated beverages, alcohol, and spicy foods); weight loss; elevation of the head of bed at night; eating smaller meals; and avoiding eating within three hours of bed time.
3. Antacids (like calcium carbonate or Tums) work very quickly but do not have a long duration of effect.
4. Bismuth subsalicylate (Pepto Bismol) covers a wide variety of indications, so it may be useful when patients complain of heartburn with nausea or upset stomach.  The subsalicylate component behaves similarly to aspirin, so warnings regarding children and those with asthma are applicable to bismuth subsalicylate.
5. H2 blockers, like ranitidine (Zantac) and famotidine (Pepcid AC), work within an hour and last most of the day.  These are excellent options for as-needed therapies among patients with moderate but infrequent symptoms.  Do not exceed twice daily dosing (or once daily for renal impairment).
6. Cimetidine (Tagamet) has numerous drug interactions and an inferior adverse effect profile compared to other H2 blockers (such as ranitidine and famotidine).
7. Proton pump inhibitors (PPIs like omeprazole, lansoprazole, esomeprazole, and omeprazole with sodium bicarbonate) take at least a day to start working, so these are not effective when dosed as needed.
8. PPIs are only indicated for patients with "frequent" heartburn (symptoms two or more times per week) and are dosed daily (not BID) for a 14-day course.  After 14 days, the packaging states that patients should wait at least 4 months before repeating a PPI course.
9. For pregnant women, consider non-pharmacologic counseling and possibly calcium or magnesium-based antacids.
10. For breastfeeding women, consider antacids or H2 blockers as first-line therapy.