Be Still, My Heartburn
What's the best way to treat acid reflux?
Acid reflux occurs when digestive acid from the belly sneaks past the lower esophageal sphincter—the muscular flap between the stomach and the esophagus—into the upper chest or throat and causes an unpleasant fiery sensation, commonly known as heartburn. Left untreated, the acid can corrode the lining of the esophagus and cause a condition called Barrett's esophagus, known to lead to cancer. That's the long-term problem.
The short term's no fun either. The most common torture of my domestic life used to be waking in the night to find that my bedside stash of Tums was tapped out. Finally, after a gantlet of holiday parties a few years ago, I saw a doctor, and he tuned me in to the powers of prevention.
Tums and other antacids are to heartburn what breath mints are to halitosis: They provide immediate and temporary relief, but they don't address the root of the problem. Prevention usually involves treating your body more like a temple and less like a fraternity house: Cut down on fried foods and alcohol; quit smoking; eliminate unnecessary stress; exercise; give yourself three hours to digest a meal before lying down.
But if you're unwilling to give up the beer, or giving up the beer doesn't help control the acid, you'll want to explore two classes of pharmaceuticals: histamine, or H2, blockers (H2s) and proton pump inhibitors (PPIs). Neither has been shown to cause any serious side effects (though they come with your typical warnings: nausea, headache, diarrhea).
H2s are over-the-counter meds that reduce acid production in the stomach. Meant to be taken before a meal, they have an advertised staying power of eight to 12 hours and are marketed toward occasional (once a week) heartburn sufferers, though more powerful doses of H2s are sometimes prescribed for those who experience frequent attacks (twice a week or more).
PPIs are supposed to work longer and harder than H2s by deactivating the pumps that produce digestive acids. They are once-a-day pills (lasting for 24 hours) that have been shown to treat heartburn symptoms and, over time, to heal the tissue damaged by the acid. Most PPIs are available only by prescription, though this past summer the FDA approved one of them, Prilosec, for OTC sale after its prescription patent had expired. (Prilosec OTC hit stores in mid-September, accompanied by a reported $100 million ad campaign.)
The conventional wisdom is that drugs in the same class are indistinguishable from one another. (One doctor I spoke to said he takes whichever PPI he finds around the office that morning.) But no head-to-head trials have been done, so who's to say? A handful of congressional leaders, according to an article in the Aug. 24 New York Times, are pushing to set aside $75 million for government-run comparative studies on drug types popular with the Medicare/Medicaid set. But that's going to take years, if it happens at all. In the meantime, I decided to spend a couple of hundred of Slate's dollars to conduct my own (highly empirical) drug trial.
Heartburn can strike at any time, but I wanted to court it, so I devised a revolving lunch plan with foods that have triggered my heartburn in the past (details below). I accompanied each meal with some combination of beer, chocolate, peppermint, blueberries, citrus, and caffeine, all of which are considered triggers by doctors.
To better my chances of rousing the acid, I performed the trial during a period of high stress: Two weeks before starting the trial, I got married; during the trial, my wife and I moved ourselves into a new apartment, then adopted a kitten. Where applicable below, I've noted specific stress factors.
I double-blind tested 12 drugs—one per day. I set aside one dose of each drug and assigned it a letter, put each dose in an envelope, marked the envelope with the corresponding letter, then placed all the envelopes in a plastic bag. In the spirit of our new partnership, my wife agreed to act as The Administrator (TA). At 11 a.m. each day, TA went into another room, pulled an envelope out of the bag, took the medicine out, wrote the date on the envelope, and placed the envelope in her sock drawer. TA then set the drug on the back of my tongue while I closed my eyes. I ate each day's lunch 60 to 90 minutes after taking the medicine, then monitored symptoms—heartburn, reflux, sourness—until around 8 that evening (when the effectiveness of an H2 would have worn off).
After the trial, I reviewed the notes I had made regarding the intensity of each day's meal. I realize that eating different lunches on different days could have skewed the results—what if, say, a burrito and a slice of blueberry pie induced more volatility than a wedge of lasagna plus Junior Mints?—and yet, for logistical and gustatory reasons, I couldn't possibly have eaten the same lunch for two weeks straight. To compensate for the potential discrepancy, I scored each lunch on an acid-inducing power scale (p), with 10 being extremely acid-inducing and 1 being hardly acid-inducing at all. I also reviewed my notes on the intensity and duration of each day's symptoms, scoring each day on a heartburn symptom scale (H), with 10 representing extremely harsh symptoms and 1 representing no symptoms. I divided the p by the H to come up with a final p/H, with the best possible score being a 10—nasty lunch, no symptoms—and the worst possible score being 0.1—light lunch, nasty symptoms. Finally, I looked at the envelopes and paired each day's results with the corresponding drug.
Note: The price for PPIs and prescription H2s varies according to insurance plan and place of purchase. Drug prices below are taken from Drugstore.com and assume no co-pay discount.
Results (from worst to first):
Aciphex (20 mg) 30 tabs/$114.99
Type: PPI; Rx
Lunch: 1 slice of pepperoni pizza; 1 beer; 1 pack of peanut M&M's
p/H (2/8) = 0.25
Notes: Considering this light lunch, the nagging reflux and heartburn I experienced surprised me, especially with a PPI. TA and I did move heavy furniture all afternoon, so physical stress was high.
Generic Ranitidine (75 mg) 30 tabs/$5.99
Type: H2; OTC
Lunch: Spicy Chinese orange beef with rice; 1 beer; 1 slice of blueberry pie; half a box of Junior Mints
p/H (5/10) = 0.5
Notes: Ranitidine, the active ingredient in Zantac, held out for only one hour before I began to feel a burn around my sternum. For most of the afternoon—despite heavy Tums use—I had a sour sting in my throat.
Placebo (cranberry capsule) n/a
Lunch: 1 grilled steak/black bean burrito with spicy salsa; 1 beer; 1 slice of blueberry pie; 1 coffee
p/H (6/8) = 0.75
Notes: The placebo effect dissipated a mere three hours after lunch, when soreness in my chest and a burn in my lower throat took over. For the rest of the day, I nursed a pack of antacids.
Zantac (75 mg) 30 tabs/$9.99
Type: H2; OTC
Lunch: 1 grilled steak/black bean burrito with spicy red salsa; 1 beer; 1 Peppermint Pattie; 1 coffee
p/H (6/4) = 1.5
Notes: Most of the day, I felt the foreshadowing of heartburn—a tickle around the sternum. Though it never rose up into the throat, a bitter tang hovered behind my ribs all afternoon.
Generic Famotidine (10 mg) 30 tabs/$7.99
Type: H2; OTC
Lunch: 8 spicy buffalo wings; 2 slices of baked ziti pizza; 2 beers (oops); 1 slice of blueberry pie; 1 Peppermint Pattie; 1 pack of peanut M&M's
p/H (10/6) = 1.6
Notes: Famotidine, the active ingredient of the Pepcid family, muffled one of my fieriest lunches. For a few hours, I was symptomless, but a midafternoon burp unleashed a quick and powerful jolt of acid that lingered until dinnertime.
Prilosec OTC (20 mg) 28 tabs/$19.99
Type: PPI; OTC
Lunch: 8 spicy buffalo wings; 1 slice of pepperoni pizza; 1 beer; 1 box of Junior Mints
p/H (8/4) = 2
Notes: With the approval of Prilosec for over-the-counter sale, uninsured heartburn sufferers now have relatively cheap access to a PPI. But this PPI didn't work as well for me as some of the H2s: A slight burn in the chest worsened as the day went on, forcing me to parry with antacids.
Axid (75 mg) 50 tabs/$13.99
Type: H2; OTC
Lunch: 1 wedge of lasagna; 1 beer; 1 slice of blueberry pie
p/H (8/3) = 2.6
Notes: I didn't expect much from a product whose name so closely resembled what it was meant to alleviate. A moderate lunch, but over the course of the day, I gorged on popcorn, beer, candy, a Reuben, nachos, and ice cream. Axid tamped it all down with only a few Tums for backup.
Prevacid (30 mg) 30 caps/$120.99
Type: PPI; Rx
Lunch: 1 slice of baked ziti pizza; 1 beer; 1 slice of blueberry pie
p/H (3/1) = 3
Notes: No heartburn until a minor burst around dinner (near the end of the testing period), and this was a stressful day—the first in our new apartment.
Protonix (40 mg) 30 tabs/$98.99
Type: PPI; Rx
Lunch: 1 grilled steak/black bean burrito with spicy red salsa; 1 beer; 1 slice of blueberry pie; 1 coffee
p/H (7/2) = 3.5
Notes: This drug benefited, I'm sure, from being chosen on day two of the trial, when my stomach acid had not yet been agitated. Still, after a jumbo lunch and an active day of moving-related errands, it kept the burn away. I did, however, have the signature "ahem" cough of reflux all day.
Pepcid AC (10 mg) 30 tabs/$9.99
Type: H2; OTC
Lunch: 1 grilled steak/black bean burrito with spicy red salsa; 1 beer; 2 slices of blueberry pie; 2 coffees; 1 Peppermint Pattie; quarter of a Lindt chocolate mint bar
p/H (10/2) = 5
Notes: Before the trial, I had never tried Pepcid AC; I'm not sure why. I ate a monster lunch and packed a ton of boxes, but I experienced only the slightest preliminary twinge of heartburn, which I addressed with a couple of precautionary Tums.
Ranitidine (150 mg) 60 tabs/$10.99
Type: H2; Rx
Lunch: 1 bacon-onion omelet with hot sauce; 1 beer; 1 slice of blueberry pie; 1 coffee
p/H (7/1) = 7
Notes: TA picked this prescription-strength generic on the last day of the trial, when my innards were scrambled after two weeks of acid-bating, and yet it still kept the acid where the acid ought to be.
Nexium (40 mg) 30 caps/$120.99
Type: PPI; Rx
Lunch: 1 hot dog with "the works"; 1 chili-cheese dog; 1 bag of chips; 1 beer; 2 Peppermint Patties; 1 chocolate ice cream cone
p/H (9/1) = 9
Notes: According to a spokesman from AstraZeneca, the company that makes both Nexium and Prilosec, Nexium has a "higher degree of bioavailability," which means either that it works better than Prilosec, or—as some critics have argued—that AstraZeneca has slightly tweaked an old drug to get patent protection for a too-similar product, guaranteeing a steady influx of dollars. However tempting it is to believe the latter, Nexium gave the superior performance of my trial. The meal was a bruiser; I experienced no symptoms; and the special stress factors that day included the installation of a window unit, a kitten under the radiator, and TA's mounting displeasure over my eating habits.
As a class, the PPIs ruled: Three of them finished in my top five. Was the difference between Nexium and Prilosec OTC enough to justify spending more for the Nexium if you don't have insurance? In a word, no. My insurance covers only generics, and, since I've made some lifestyle changes that have helped control my heartburn—less beer, less junk, more exercise—I plan to go with the prescription Ranitidine (which costs me only $10 for 60 tablets). That's a much better deal than any of the PPIs—even the Prilosec OTC—not to mention the less powerful OTC H2s. If, for some reason, I couldn't get to my Ranitidine, I'd go with Pepcid AC or Axid. And for what I hope are rare middle-of-the-night attacks, I'll keep a jar of Tums by the bed.
Chip Brantley is the author of The Perfect Fruit, a book about pluots.
Illustration by Mark Alan Stamaty.