Agonising heartburn? What you must know pills before after you all start taking the pills
HEARTBURN is a problem shared by millions of Britons, with as many as one in five adults having regular attacks. Also known as reflux, it occurs when acid from the stomach splashes up into the oesophagus, causing pain and inflammation. this happens when the lower oesophageal sphincter — a muscular valve at the bottom of the gullet that opens to let food into the stomach, then closes behind it — is weakened, often due to irritation from alcohol or fatty foods or as a result of long-term weight gain.
As we explained last week, heartburn should never be ignored. Left untreated, it is a leading cause of oesophageal cancer as, over time, the acid splashing up into the oesophagus can cause the cells to change.
But are heartburn pills the best treatment? these have now become one of the most commonly prescribed drugs in the UK. Every year in England alone, the NHs spends more than £100 million on PPIs (proton pump inhibitors), drugs which reduce acid production.
Experts stress that if you have reflux regularly, the first thing to try is to look at your diet and other habits.
Last week, we revealed the surprising triggers that can make heartburn worse, such as pastry (the high fat content increases stomach acid production) and prosecco (if bubbles make you burp, this can bring up acid).
Losing weight can help — extra pounds mean more pressure on the oesophageal valve — as can quitting smoking and avoiding excessive alcohol.
But lifestyle changes alone may not be enough. Many people only suffer with reflux from time to time, and manage it with overthe-counter medications such as antacids and drugs known as H2 blockers.
those who have it more severely may need to take regular medication, usually PPIs.
WHAT ABOUT THE SIDE-EFFECTS?
‘EVERYBODY’s on a PPI these days — it’s epidemic,’ says Peter Whorwell, a gastroenterologist at the University Hospital of south Manchester NHs trust.
‘But patients are getting more knowledgeable and are worried about long-term effects.’
A growing body of evidence is linking the drugs to a raised risk of conditions such as osteoporosis (crumbling bones), infections such as C. difficile (a potentially deadly gut bug), heart attacks, kidney failure and, most recently, dementia.
these may occur because the dramatic reduction of stomach acid can reduce the absorption of minerals from food — hence the link with osteoporosis — or they reduce the stomach’s ability to kill bacteria from food, allowing bacteria such as C. diff to flourish.
However, these studies on PPIs are epidemiological — proving an association, rather than a causal effect — and not considered to be particularly high- quality evidence, says Nicholas Boyle, a consultant upper gastrointestinal surgeon at Maidstone and tunbridge Wells NHs trust and Bupa Cromwell Hospital in London.
He adds: ‘For most people, my advice would be that PPIs are safe and very effective.
‘the problem is that these pills are being given out on repeat prescription and many patients are taking them year after year.
‘they have a place, but we should try to minimise their use. the NHs has now issued guidance to GPs, saying they should be reviewing patients regularly to see whether they can reduce or cut out PPIs.’
Professor Whorwell agrees. ‘Heartburn is horrible and PPIs are life- changing for some people. But we should try to treat the patient, rather than take a one-size-fits-all approach.’ the good news is that, in the past five years, our understanding of reflux and its causes has improved dramatically, allowing doctors to devise a more tailored treatment plan.
TESTS SHOW IF YOU DO NEED PILLS
NEW tests — available on the NHs — mean that doctors can better establish what may be causing a patient’s reflux (or, indeed, rule out reflux and show that another condition is causing their symptoms).
For instance, they can help distinguish between silent reflux, where stomach acid causes symptoms other than heartburn (see box, right) and non-erosive reflux — with the latter, patients have heartburn, but tests show no sign of damage to the oesophagus, suggesting that it’s non-acidic contents from the stomach that are splashing up, so taking PPIs to reduce stomach acid may not help.
‘We can measure everything that’s happening inside,’ says Dr Anthony Hobson, a gastrointestinal physiologist and clinical director of the Functional Gut Clinic, who also carries out specialised reflux investigations at several NHs centres.
‘If the patient is on medication, we can use these tests to check it’s working and, if necessary, try another medication,’ he says.
‘ It doesn’t mean that the treatment or surgery they’ll have is always a success, but it certainly means that people are getting the right treatment at the right time, rather than being
put on a PPI they may not need for 20 years.’
One new type of investigation is oesophageal manometry, where a probe around 2.5mm in diameter and covered in pressure sensors is inserted through the nose and down into the stomach. This allows doctors to look in detail at how well the entire oesophagus and stomach are functioning.
‘Patients are often terrified about coming for this test because it’s done without any sedation, but it’s actually really gentle and only lasts between ten and 20 minutes,’ says Dr Hobson.
Patients may also be sent home for 24-hour monitoring of their stomach acid, via a smaller probe that’s inserted down the throat on a thin tube — this measures the amount of acid produced and the level of acidity.
AVOID LONG-TERM USE OF ANTACIDS
ANTACIDS — sold in pharmacies without prescription under names such as Rennie and Gaviscon — will neutralise the effects of stomach acid.
They come in the form of tablets or liquid and some also contain an alginate, which coats the stomach contents to stop them rising up and protects the gullet from acid.
These provide short-term relief, but don’t treat the root of the problem and shouldn’t be used long-term, says nicholas Boyle.
He adds: ‘Antacid tablets mask symptoms of reflux, often success- fully — 1.5 million people take them regularly. But they don’t address the fundamental problem, which is not excessive acid, but failure of the valve that normally keeps gastric contents in the stomach.’
Many people safely take antacids for heartburn, he says, but ‘anyone with persistent heartburn that goes on for more than two weeks should see their doctor’.
Patients with other symptoms, such as a persistent sore throat or cough, particular difficulty swallowing or unexplained weight loss, should also seek medical opinion.
OTHER DRUGS THAT COULD DO THE TRICK
As well as antacids, another alternative to PPIs are H2 blockers, or H2 receptor antagonists. like PPIs, they work by reducing the production of stomach acid, but use a different mechanism.
They include cimetidine, famotidine, nizatidine and ranitidine (sold under brand names such as Zantac). You can buy these over the counter, although if your heartburn is persistent, your doctor may give you a prescription.
‘They act quite quickly and last for three or four hours, and people can take them as and when they need them — unlike PPIs, which they need to take every day,’ says Dr Hobson.
There are no safety issues with them, adds Professor whorwell, ‘ but if your heartburn is not responding quickly and it persists for a few weeks, and especially if you’re in your 40s or older, it’s probably worth seeing a doctor to rule out anything sinister.’
low- dose PPIs are also now available over the counter, but again, experts say these should not be taken for more than two weeks.
PPIs are generally more effective on heartburn symptoms than H2 blockers, but Professor whorwell advises starting with H2 blockers (with lifestyle changes), as these reduce acid in a more gentle way.
‘It makes sense to me to reduce acid by a bit, rather than a lot. But GPs, who are trying to turn over thousands of patients, are inclined to stick people on a PPI, because they know they’ll get rid of their symptoms straight away.’
Professor whorwell suffers with heartburn himself and treats it by taking Zantac at night.
Other drugs sometimes prescribed for reflux include pro-kinetic drugs to speed up the passage of food through the stomach and help reduce bloating and belching, which worsen the problem.
some patients benefit from antidepressants to reduce pain and sensitivity in the gullet, particularly in non- erosive reflux, where treating acid won’t be effective.
WHY IT’S WORSE WHEN YOU STOP
THE general advice is not to come off prescription PPIs without medical advice.
One problem that makes it hard for people to stop taking PPIs is that, when they do, they can experience a rebound response, where the stomach produces high levels of acid and reflux comes back with a vengeance.
This does settle down, explains surgeon nicholas Boyle, but it can take several weeks to do so and, in the meantime, the heartburn and other symptoms can be so bad that the patient ends up taking pills again. ‘It can be quite difficult to wean off them,’ he adds.