Treatment of severe acidity (acid reflux, heartburn, acid-peptic disease)

1. See a doctor urgently if any of these are present

• Difficulty or pain on swallowing
• Unintentional weight loss
• Vomiting blood, or black or tarry stools
• Anaemia
• Persistent vomiting
• Chest pain, especially with sweating or breathlessness (this may be cardiac)
• Age over 50 with new symptoms

2. Lifestyle measures (alongside drugs, not instead of them)

• Lose weight if overweight.
• Avoid large, spicy and fatty meals, and avoid late meals. Stop eating at least 3 hours before bed.
• Raise the head of the bed.
• Stop smoking, and cut down on alcohol, coffee and acidic drinks if they trigger symptoms.
• Avoid NSAIDs (aspirin, ibuprofen, diclofenac) where possible. They are a common cause of ulcers.

3. Drug treatment (stepwise)

• Antacids (aluminium/magnesium hydroxide) or alginates (e.g., Gaviscon) work within minutes. They are only for occasional, short-term relief.

• They suit mild or night-time symptoms. They are weaker than PPIs and tolerance develops.

• For classic heartburn or regurgitation without alarm features, the 2022 ACG guideline recommends an 8-week empiric trial of a PPI once daily.
• Take it 30 to 60 minutes before a meal, not at bedtime.
• If symptoms persist, check adherence and timing. Then consider twice-daily dosing (the ACG and AGA recommend this step).
• If symptoms respond, try to stop or step down to the lowest effective dose. Patients with erosive oesophagitis (LA grade B to D) or Barrett's oesophagus need long-term maintenance.
• PPIs are preferred over H2 blockers for healing and maintaining remission of erosive oesophagitis.

• Sucralfate or prokinetics may help selected patients.
• Surgical or endoscopic anti-reflux procedures (fundoplication) are for refractory, objectively proven GERD.

4. If peptic ulcer is the cause

• Acid is essential to ulcer formation, and nearly all peptic ulcers heal with PPIs (Bailey and Love's Short Practice of Surgery, 28th Ed, Peptic Ulcer section).
• Test for H. pylori (breath, stool antigen or biopsy) and eradicate it if present. Typical 7 to 14 day regimens are:
  • Bismuth quadruple therapy: PPI twice daily, bismuth, tetracycline and metronidazole.
  • Triple therapy: PPI, amoxicillin and clarithromycin. Use it only where clarithromycin resistance is low.
  • Non-bismuth quadruple (concomitant) therapy: PPI plus three antibiotics for 10 to 14 days.
  • Where clarithromycin resistance is above 15% or unknown, Harrison's recommends bismuth quadruple therapy (Goldman-Cecil Medicine, Table 125-4; Harrison's Principles of Internal Medicine, 22nd Ed, Therapy of H. pylori).
• Stop NSAIDs, or add PPI protection if they cannot be stopped.
• Zollinger-Ellison syndrome (gastrinoma) causes very high acid output and needs high-dose PPIs.

5. Cautions with long-term PPI use

• Use the lowest effective dose and review the need regularly.
• Possible risks include low magnesium, B12 deficiency and a small increase in fracture and infection risk. ACG notes that the evidence for harm is mostly observational.
• Rebound acid hypersecretion can occur after stopping, so taper gradually.

6. Emergencies