How safe are heartburn medications and who should use them?

ABSTRACT

Introduction

Heartburn is a frequent symptom occurring in daily clinical practice and is mainly associated with gastroesophageal reflux disease (GERD). However, it can be stimulated by various factors and diseases other than GERD can present with heartburn. Therefore, physicians must be very careful in distinguishing GERD from non-GERD conditions in their patients, particularly when heartburn is refractory to anti-reflux medications.

Areas covered

The aim of this narrative review was to analyze the medical literature regarding the prevalence of heartburn and the various clinical disorders which can be present with this symptom. The type of medications usually adopted for treating heartburn and their grade of safety have been reviewed using an extensive computerized (Medline/PubMed) search with particular focus on the last 20 years.

Expert opinion

Many drugs can be used for relieving heartburn in patients with GERD, although PPIs are the pharmacological agents with the greatest efficacy. However, it must be highlighted that many non-GERD conditions may present clinically with this symptom whose intensity does not differ between GERD and functional esophageal disorders, which represent about 50% of all patients with suspected GERD. It is very important to identify these functional conditions because their treatment differs completely from that of GERD.

KEYWORDS:

• Heartburn
• typical symptoms
• GERD
• esophageal functional disorders
• medication safety
• indications for heartburn medications
• Non-GERD heartburn

Article highlights

• Heartburn is a frequent symptom in daily clinical practice and is the most typical manifestation of the various presentations of gastro-esophageal reflux disease (GERD)

• However, it is not stimulus specific in that its generation can be due to both chemical and non-chemical (thermal, mechanical, and electric) factors and therefore there are many non-GERD diseases that can present with the symptom heartburn

• Heartburn severity does not differ among GERD phenotypes or between GERD and functional esophageal disorders, such as functional heartburn

• Heartburn medications are represented by the various compounds adopted for treating GERD in its various forms (antacids, alginate, mucosal protectans, antisecretory drugs, prokinetics, baclofen), being at present PPIs the first-choice therapy in both the short and the long term

• Heartburn due to functional esophageal disorders should be treated with neuromodulators, such as tricyclic antidepressants or selective serotonin reuptake inhibitors in the attempt of reducing esophageal hypersensitivity

• The above medications for treating heartburn are relatively safe and their adverse events are comprised within 1%–3% of all patients treated, as in many other therapeutic settings

• The alarming adverse events published recently on chronic PPI therapy must be taken with great caution because the studies reporting them present many methodological flaws, mainly the observational and retrospective design and the lack of correction for possible confounders

• Heartburn due to non-GERD conditions should be treated with medications other than those used for GERD and they differ in relation to the different diseases (e.g. achalasia, eosinophilic esophagitis not responding to PPIs, supra-gastric belching, rumination, vomiting syndromes, gastroparesis, functional heartburn).

Declaration of Interest

E Savarino has served as speaker or consultant for Abbvie, Alfasigma, Dr. Falk, Janssen, Pfizer, Reciti, Takeda and received research support from Pfizer, receipt and Sofar. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.