Acid reflux / heartburn

Medical information

Written and reviewed by a team of doctors. Dr Fox is regulated by the CQC & GPhC.

Acid reflux, acid indigestion, and heartburn

Acid reflux, heartburn, and acid indigestion are used interchangeably. Doctors often use GORD (gastro-oesophageal reflux disease). They are all terms describing the burning pain caused by stomach acid.

Acid produced in the stomach can travel up to the gullet and the back of the throat. This produces a burning sensation in the region of the breastbone (heartburn) and occasionally a taste of acid in the throat and can also lead to gullet inflammation.

Acid reflux treatment

Dr Fox supplies strong acid suppressant medications (from the PPI class of medicines) for the treatment of reflux (GORD):

• Omeprazole 10mg/20mg (Losec)
• Esomeprazole 20mg (Nexium)
• Pantoprazole 20mg

Dr Fox used to supply Zantac (ranitidine) but it was withdrawn by the manufacturers in October 2019. There is an ongoing investigation into a contaminant and it is unclear if and when production will start again (September 2023).

Frequency of acid indigestion

Almost everybody will experience acid indigestion from time to time. It can be brought on by spicy food or by drinks such as wine, beer, or acidic fruit juice. Most acid indigestion will settle with antacids containing an alkali (chalky tablets or milky liquids).

Some people are prone to repeated episodes of acid reflux. For these people a proton pump inhibitor (PPI) taken daily for few days will usually settle symptoms for a week or two at a time. Indigestion symptoms can usually be kept under control by taking a PPI capsule or tablet on an as required basis.

PPIs reduce the level of acid production in the stomach. If there is less acid then symptoms of acid reflux and heartburn are reduced.

GPs normally investigate acid reflux symptoms when they are severe, are changing, or do not respond to simple antacid and acid suppressant treatments. This is to exclude more serious causes, including ulcers and cancers, that could require different treatments.

Self help for acid reflux

• Weight loss if overweight or obese - check using a BMI calculator.
• Avoid obvious trigger foods e.g. cola, acidic fruits and acidic vegetables, fatty or spicy foods.
• Eat smaller portions and have evening meals at least 4 hours before bedtime.
• Stop smoking - smoking increases the production of stomach acid.
• Reduce alcohol intake - alcohol (and cocaine) can cause inflammation of the stomach (gastritis).
• Look at ways to reduce stress and anxiety - these can trigger more acid production.
• Take antacids (e.g. Gaviscon, Rennie, Pepto Bismol) to neutralise stomach acid.
• Some other medications (especially anti inflammatory tablets) can trigger reflux/indigestion - discuss with your GP if you think this may be the cause.

Further information: NHS - Indigestion.

Medication and dosage

For people with mild or occasional symptoms taking a PPI for 4-5 days will settle the problem, usually for a few weeks at the time.

Omeprazole 10mg/20mg capsules

The starting dose of omeprazole (Losec or generic) is one 10mg or one 20mg capsule daily. It is usually recommended to start with the lower dose of 10mg and increase to 20mg if symptoms are not controlled by the lower dose. It can be taken regularly for up to 4 weeks. After this, one or two 10mg omeprazole capsules or one 20 mg capsule daily can also be taken on an 'as required' basis when symptoms flare up.

Esomeprazole 20mg tablets

Esomeprazole 20mg tablets (Nexium or generic) should be taken once a day at the same time of day. Symptoms should improve after 4-5 days, and it can be taken for up to 4 weeks. Once symptoms have settled esomeprazole tablets can be taken 'as required' if symptoms flare up again.

Pantoprazole 20mg tablets

Take one pantoprazole 20mg tablet once a day, one hour before a meal at the same time each day. Use daily for up to 4 weeks. If symptoms come back, one pantoprazole 20mg tablet can be taken once a day, as needed.

How to choose which PPI

There is very little to choose between the different PPIs in terms of side effects, interaction with other medications, and overall efficacy at treating acid reflux/indigestion.

Dr Fox recommends starting with the lower dose omeprazole 10mg capsules once or twice a day or one 20mg capsule daily. Esomeprazole 20mg and pantoprazole 20mg are stronger tablets for once daily use. If taking other medications as well, pantoprazole may be better as there are fewer interactions (checks are made in the online consultation questionnaire). Patients report the fewest side effects with pantoprazole.

Are there any risks of taking strong acid suppressants/PPIs?

PPIs have been safely used for over 30 years.

PPIs may affect some other medications. Further information in manufacturers patient leaflets (interaction checks in the online consultation). If in doubt discuss with your GP or pharmacist.

If there is a known allergy to a particular PPI, do NOT take a different one as the allergy is often shared.

The main risk of taking PPIs is the danger of masking the symptoms of a cancer in the stomach or gullet and so in some situations a GP should be consulted before using a PPI.

PPIs may also affect blood tests and other medical investigations. Always tell your doctor or nurse that you are taking a PPI when having a test or investigation. In some cases you will be asked not to take it for a few weeks before the procedure.

When to consult a doctor

It is important to consult a GP before ordering a PPI if any of the following apply:

• Aged 55 years or over and either:
  • New onset of symptoms within the last year
  • or, where symptoms are worsening or changing.
• Any age with reflux or heartburn and any of:
  • Unintentional weight loss.
  • Anaemia.
  • Difficulty or pain on swallowing.
  • Frequent vomiting, particularly if there is blood in the vomit.
  • Black, shiny or bloody stools or new persistent diarrhoea.
  • Previous gastric ulcer or gastric surgery.
  • Jaundice or severe liver problems.
  • Persistent upper abdominal pain or new unexplained abdominal lump.
• You have had to take an antacid or acid suppressor continuously for 4 or more weeks in order to control symptoms.
• You have taken an indigestion or heartburn remedy for two weeks with no relief of symptoms.
• You are not sure about the symptoms or have never seen a doctor about acid problems.

Consult a GP after a course of PPI if any of the following apply:

• A short course of a PPI for up to 2 weeks does not control symptoms.
• Symptoms return immediately on stopping tablets.
• You need to take a PPI on most days after completing the initial course.

If symptoms improve with treatment, but come back when it is stopped, your GP may want to test for H. pylori, which is a bacterial infection of the stomach which can be associated with reflux symptoms. If the H. pylori test is positive, a course of antibiotic eradication treatment alongside a PPI is usually prescribed.

PPIs in pregnancy and breastfeeding

No medication should be taken unless absolutely necessary in pregnancy.

No adverse effects have been noted with omeprazole (Losec) in pregnancy or breastfeeding. Dr Fox does not prescribe in pregnancy or if you are breastfeeding, but they can be taken if you are advised to do so by your GP.

See also Best use of medicines in pregnancy - omeprazole.

There is little data about the use of esomeprazole (Nexium) and pantoprazole in pregnancy and breastfeeding and the manufacturers advise not to use.

Side effects

All PPIs are well-tolerated and side effects are generally mild and reversible. Headache, diarrhoea, nausea, abdominal pain, and rash are among adverse side effects reported. Pantoprazole has the least frequency of side effects. Full details are found in the manufacturer's patient leaflets for each product.

Dr Fox supplies acid reflux medication on prescription – you are required to answer a short medical questionnaire before your order can be completed.

Authored 30 June 2010 by Dr Tony Steele
MB ChB Sheffield University 1983. Former hospital doctor and GP. GMC no. 2825328

Reviewed by Dr C. Pugh, Dr B. Babor, Dr A. Wood
Last reviewed 11 March 2021
Last updated 30 November 2023
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