Acidity and GERD: Why Antacids Eventually Stop Working
Almost everyone gets occasional heartburn. When it becomes a daily event managed with a daily antacid, something different is going on, and continuing to treat it the same way tends to stop working.
Occasional acidity versus reflux disease
Heartburn is a symptom: a burning sensation rising behind the breastbone, often after meals or on lying down. Gastro-oesophageal reflux disease, or GERD, is the condition where reflux is frequent enough or damaging enough to cause troublesome symptoms or injury to the oesophageal lining.
Rough dividing lines are symptoms twice a week or more, symptoms that disturb sleep, symptoms needing regular medication, or any alarm feature.
Why reflux happens
A ring of muscle at the bottom of the oesophagus, the lower oesophageal sphincter, normally stays closed. Reflux occurs when it relaxes inappropriately, when pressure inside the abdomen pushes contents upwards, or when part of the stomach slides into the chest through the diaphragm, which is a hiatus hernia.
Contributors include excess abdominal weight, large or late meals, alcohol, smoking, pregnancy, delayed stomach emptying, and medications such as calcium channel blockers, nitrates, some asthma drugs and certain antidepressants.
The two kinds of “antacid”
This distinction explains most of the confusion.
Simple antacids such as magnesium and aluminium hydroxide or calcium carbonate neutralise acid already present. They act within minutes and last one to two hours. They are for occasional use.
Acid suppressants reduce acid production. H2 blockers such as famotidine act within an hour and last several hours. Proton pump inhibitors such as omeprazole, pantoprazole and esomeprazole block the acid pumps and take one to four days to reach full effect, lasting a day or more per dose.
Many people take a PPI as though it were a rescue medicine, swallowing one when symptoms start. It does not work that way, and this misuse is a common reason treatment appears to fail.
Why long-term use seems to stop working
Several things happen.
Timing errors. PPIs only inhibit pumps that are active, so they must be taken 30 to 60 minutes before a meal, usually before breakfast. Taken after food, or at bedtime on an empty stomach, much of the dose is wasted.
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Tolerance to H2 blockers. Their effect reduces over weeks of continuous use.
The symptom is not acid. A substantial minority of persistent heartburn is functional heartburn or reflux hypersensitivity, where acid exposure is normal but perception is heightened. Acid suppression cannot fix that, and doubling the dose does not help.
Rebound acid hypersecretion. After weeks of PPI use, stopping abruptly causes a temporary surge in acid production, which feels like the disease returning and drives people back onto the drug indefinitely.
Something else entirely. Eosinophilic oesophagitis, gastroparesis, gallstones, peptic ulcer, Helicobacter pylori infection, cardiac pain and even oesophageal cancer can all present as “acidity”.
Measures that genuinely reduce reflux
- Lose abdominal weight if present, which has the largest effect of any lifestyle measure
- Eat smaller meals and stop eating at least three hours before lying down
- Raise the head of the bed by about 15 to 20 cm using blocks under the bed legs, rather than extra pillows, which bend the abdomen and can worsen it
- Sleep on the left side
- Reduce alcohol and stop tobacco
- Identify personal triggers rather than banning foods universally. Common ones are chilli, tomato, citrus, coffee, chocolate, mint, fried food and fizzy drinks, but they differ between people
- Loosen tight waistbands
- Review medications with your doctor
- Treat constipation, which raises intra-abdominal pressure
- Avoid vigorous exercise immediately after eating
Using PPIs sensibly
Taken correctly, PPIs are effective and generally safe. Reasonable principles are:
- Take 30 to 60 minutes before the first meal of the day
- Use a defined course, commonly four to eight weeks, then reassess
- Step down to the lowest effective dose, or to on-demand use, rather than continuing by default
- Taper rather than stopping abruptly, to avoid rebound
- Long-term use has been associated with low magnesium, low vitamin B12, reduced calcium absorption, some enteric infections and possible kidney effects. The associations are mostly modest, but they justify using the drug for a reason rather than a habit
When to see a doctor rather than a pharmacy
Seek assessment for:
- Difficulty or pain on swallowing, or food sticking
- Unintentional weight loss
- Vomiting blood, or black tarry stools
- Persistent vomiting
- Anaemia
- Symptoms that began after age 50
- Symptoms lasting more than four to eight weeks despite treatment
- Chest pain with exertion, sweating or breathlessness, which needs cardiac assessment first
- Chronic cough, hoarseness or dental erosion, which may be extra-oesophageal reflux
Investigation may include an endoscopy, testing for Helicobacter pylori, or pH monitoring.
This article is general information. Do not start, stop or extend long-term acid suppression without medical advice, and take new or changed chest symptoms seriously.