By: Dr. Frank Macmillan – May, 2014
It seems as though everyone I know is on or has been on medication for acid reflux symptoms. Over-the-counter antacids, histamine H2 blockers, and acid-pump (proton-pump) inhibitors are among the most widely used medicines in the history of modern medicine. Why is everybody seemingly on this stuff?
First, acid reflux is very common. Stomach contents are normally acidic, and the contents will rise backwards into the chest in almost all of us on occasion. Normal acid exposure of the esophagus (swallowing tube that goes mouth to stomach) should be less than 4% of the time. This means that the esophagus does see stomach acid, and this is entirely normal and expected. When exposure exceeds 4%, then that individual has “acid reflux disease”.
Heartburn is a sensation that many people experience (a sense of burning/acid rising in the chest), though this symptom is unreliable at predicting who has serious disease. Some with severe burning in the chest may not have serious acid exposure on testing. Others may barely complain of heartburn, but may have severe acid created chemical burns and erosions of the lining of the esophagus when tested by endoscopy (a visual exam using a thin flexible camera). Testing is recommended precisely because symptoms do not reliably predict test finding when symptoms of acid reflux are self reported.
Over 50% of American adults may meet the 4% time criteria for acid reflux disease which helps to explain why so many seek treatment. Available medicines, particularly acid pump inhibitors (Prilosec, omeprazole and others), are extremely effective, have few obvious side effects, and have become relatively inexpensive over time. While we don’t entirely understand why acid reflux develops, certainly there are factors that increase risk, like obesity, tobacco and alcohol abuse, and overeating. But, we all know people with acid reflux disease who have none of these risk factors, so for many of us the explanation is not obvious.
Antacids have been around since your grandmother used vinegar or baking soda to neutralize stomach acid for heartburn. Effective medications, the H2 histamine blockers, became available in the mid 1970s and were prescription only. They were effective for some, but resistance occurred with chronic use, making them less than ideal. By the time of the late 1980s, the “purple pill” Prilosec revolutionized the treatment of acid related disorders by inhibiting the acid pump on the membrane of the cell that makes stomach acid. For the first time, healing of acid-induced esophageal injury became possible with an oral medication. This was an enormous advance in treatment, but like all good things, acid pump inhibitor medicines are over-prescribed, inappropriately prescribed, and used without a prescription for purposes for which they were not intended to be used.
Acid reflux disease occurs on a spectrum from minor heartburn to severe esophageal injury with compromised swallowing and Barrett esophagus (a precancerous condition that develops in a small minority of people with chronic acid reflux disease). Risk factors such as heartburn more than twice a week, over age 40, male gender, or difficult or painful swallowing get attention, may trigger an endoscopy to see if damage or Barrett esophagus is present. For others with heartburn, I recommend a two week trial of an acid pump inhibitor such as omeprazole (Prilosec) which you can buy over the counter for $10-15. The medicine should always be stopped after two weeks, and results discussed with your doctor. For many, heartburn will go away, but if persistent, then endoscopy may be needed to be sure. Medication side effects are uncommon, but potentially serious vitamin B12, calcium, magnesium and iron deficiency can result, as can intestinal infections with C. dificile occur with greater frequency. For those on long-term acid suppressive medication, careful monitoring by a physician familiar with acid reflux disease is a very good idea to be certain that symptoms remain controlled, risk of side effects minimized, and that alarm signs are being looked for. Remember, these are serious medicines and not a vitamin supplement to be taken without careful consideration.
Dr. Frank MacMillan, Jr, MD, FACG specializes in Gastroenterology and Liver diseases, is a Fellow of the American College of Gastroenterology and is its Massachusetts Governor. He is Vice President of the Massachusetts Gastroenterology Association. Dr. MacMillan is a native of North Andover and practices Gastroenterology in Haverhill at Merrimack Valley Hospital, where he currently serves as the Chief of Medicine. He has also been a member of the North Andover Board of Health since 2007.