Management of Heartburn

Initial Treatment Algorithm

The American College of Gastroenterology recommends starting with as-needed antacids or low-dose H2-receptor antagonists for occasional heartburn, and initiating once-daily proton pump inhibitor therapy for frequent symptoms, with a strength of evidence of Grade B 1, 2
Antacids provide relief within minutes and are more effective than placebo for individual heartburn episodes, with a response rate of 80-90% 1
Low-dose H2RAs provide relief within 30-60 minutes, lasting up to 12 hours, and are superior to antacids, with a number needed to treat of 2-3 1
The American Gastroenterological Association recommends advancing to short-course PPI therapy if symptoms occur more than 2-3 times weekly or H2RAs provide insufficient relief, with a strength of evidence of Grade A 1, 2

The American Heart Association strongly recommends weight loss for all overweight or obese patients, with dose-dependent benefits and significant symptom reduction, and a strength of evidence of Grade B 4, 5, 1, 3
Elevating the head of the bed is recommended for patients with nighttime heartburn or regurgitation when recumbent, with a reduction in symptom severity of 50-70% 4, 5, 1, 3
Avoiding lying down for 2-3 hours after meals can reduce esophageal acid exposure by 30-50% 1, 3
Identifying and avoiding specific food triggers can reduce symptom severity by 20-40% 4, 1

Increasing to twice-daily PPI dosing can provide additional symptom relief in 50-70% of patients 3
Adding alginate-containing antacids can provide breakthrough symptom relief in 30-50% of patients 5, 2
Considering adding bedtime H2RA for nocturnal symptoms can provide symptom relief in 40-60% of patients, though tachyphylaxis limits long-term use 5, 2

Extraesophageal symptoms such as chronic cough, hoarseness, and asthma are less likely to respond to PPI therapy, with a response rate of 20-40% 5
Twice-daily PPI for 8-12 weeks minimum is recommended for extraesophageal symptoms, with a strength of evidence of Grade B 3
Investigating non-GERD causes is recommended before proceeding to extensive testing if PPI therapy fails, with a strength of evidence of Grade C 5

Failure to optimize PPI timing can reduce efficacy by 30-50%, and must be taken 30-60 minutes before meals, not at bedtime or with meals 2
Assuming GERD is ruled out after failed empiric therapy without objective testing can lead to misdiagnosis in 20-40% of patients, and many patients require endoscopy or pH monitoring for accurate diagnosis 2
Using metoclopramide as monotherapy or adjunctive therapy has an unfavorable risk-benefit profile, with a number needed to harm of 5-10 3
Continuing long-term PPI without periodic reassessment can lead to potential long-term risks, and regularly evaluating the need for continued therapy is recommended, with a strength of evidence of Grade C 3