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, heartburn, GORD, and dyspepsia

Acid reflux, heartburn, and acid indigestion are often used interchangeably. Doctors may also use GORD/GERD (gastro-oesophageal reflux disease). They are all terms describing the symptoms 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.

Dyspepsia is a medical term which covers a group of symptoms, including acid reflux and heartburn, but also upper abdominal/belly discomfort and occasional nausea or vomiting. Many people call this 'indigestion'. Studies show that most dyspepsia is 'functional dyspepsia' caused by a combination of factors, including gut/brain miscommunication and too much acid production.

Stomach acid suppression treatment

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

• Omeprazole 10mg/20mg (Losec)
• Esomeprazole 20mg (Nexium)
• Pantoprazole 20mg
• Lansoprazole 15mg/30mg
• Rabeprazole 10mg/20mg (Pariet)

Only one type of PPI may be ordered at a time as they should not be taken together.

Dr Fox used to supply Zantac (ranitidine) but it was withdrawn by the manufacturers in October 2019.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 (April 2024).

Frequency of acid stomach symptoms

Almost everybody will experience 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 a few days will usually settle symptoms for a week or two at a time. Indigestion/dyspepsia symptoms can usually be kept under control by taking a PPI capsule or tablet on an as required basis. If you are finding that you need to take a PPI on an almost daily basis for more than a few weeks it is important to discuss this with your regular doctor

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

GPs normally investigate acid reflux and dyspepsia symptoms if they are severe, are changing, are associated with weight loss, or with food sticking in the throat, or they do not respond to simple antacid and acid suppressant treatments. This is to check for more serious causes, including stomach ulcers and cancers, that could require different treatments.

Self help for acid reflux and dyspepsia symptoms

• Weight loss if overweight or obese - check using a BMI calculator.
• Regular aerobic exercise (bending exercises not recommended with GORD).
• Avoid obvious trigger foods e.g. cola, coffee, acidic fruits and acidic vegetables (tomatoes), chocolate, 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 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 should settle the problem, for a few weeks at a 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.

Rabeprazole 10mg/20mg tablets

Starting dose is one 10mg tablet in the morning half an hour before breakfast. Can be increased to 20mg daily either as two 10mg tablets, or one 20mg tablet in the morning, or one 10mg tablet twice a day (morning and evening). Use for up to 4 weeks. If symptoms come back, continue rabeprazole at the lowest dose needed for control.

Lansoprazole 15mg/30mg capsules and orodispersible tablets

Take one 15mg capsule or orodispersible tablet once a day, increasing to 30mg daily if necessary to fully control symptoms. (30mg can be made up from: One 30mg tablet or capsule in the morning; Two 15mg tablets or capsules together in the morning; Or one 15mg tablet or capsule twice a day, morning and evening). Use daily for up to 4 weeks. If symptoms come back, take lansoprazole 15mg or 30mg, 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 (see below).

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, symptoms are worsening or changing.
• Any age with reflux or heartburn and any of:
  • Unintentional weight loss.
  • Anaemia (pale, lethargic).
  • 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.

Helicobacter pylori (H. pylori)

H. pylori is a bacterial infection of the stomach which can be associated with dyspepsia and reflux symptoms. The test is usually either a simple stool (poo) test or breath test. For the test to be reliable, you must not have taken a PPI in the past 2 weeks, or antibiotics in the past 4 weeks. Your GP may suggest you need this test if your symptoms do not settle with treatment and you can speak to them about this or order an H. pylori self test online which Dr Fox could provide. If the H. pylori test is positive, a combination course of antibiotic eradication treatment alongside a PPI is usually prescribed by your GP (H. pylori eradication treatment is not available from Dr Fox).

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 it 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), lansoprazole (Zoton FasTab), rabeprazole (Pariet), 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.

Effects of taking PPIs long term

• Slight increase in the risk of fractures at the hip, wrist, and spine, hence patients are recommended to follow national guidelines for prevention and treatment of osteoporosis, and to have an adequate intake of calcium and vitamin D.
• Reduced absorption of vitamin B12 if taking regularly for more than 2-3 years. Risk is further increased if also taking regular steroid medication.
• Low magnesium levels. Symptoms include fatigue, dizziness, confusion, fits, and irregular heart rhythms. More likely if taken with other drugs (e.g. digoxin) which can also lower magnesium levels. Periodic checks of blood magnesium levels may be recommended if taking for longer than 3 months continuously.
• A rare condition 'subacute cutaneous lupus erythematosus' (SCLE). Consult your GP promptly if you develop a skin rash on sunlight exposed areas.
• A slightly higher risk of gastroenteritis such as Campylobacter and Salmonella.
• Some people who have taken PPIs for many years are found to have benign polyps in their stomach when having a routine gastroscopy. These do not usually cause any problems, and settle on stopping the PPI.
• Research published in 2023 seems to show a link with long term use of PPIs and the development of dementia in later life. More research is needed to clarify this.

Taking a PPI 'off-label' for dyspepsia/indigestion

PPIs are recommended by NICE for use in dyspepsia but the original manufacturers' licences did not include this. PPIs for dyspepsia are therefore supplied off-label with the doctors taking responsibility for prescribing.

Buy treatment

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

1. Medical questions
2. Choose treatment
3. Complete order

Answer medical questions to order(acid reflux)

Honest & accurate responses are necessary for safe medical assessment