Acidity and GERD: Why Antacids Stop Working

Almost everyone has heartburn occasionally. When it happens twice a week or more, or starts to affect sleep and eating, it is gastro-oesophageal reflux disease, and it is worth treating properly rather than reaching for another antacid.

What is actually happening

A muscular ring at the bottom of the oesophagus, the lower oesophageal sphincter, normally keeps stomach contents down. When it relaxes at the wrong times, or when pressure inside the abdomen is high, acid moves upward into a lining that has no protection against it.

The result is burning behind the breastbone, a sour taste, and sometimes a cough or hoarseness that is never traced back to the stomach.

Symptoms beyond heartburn

• Regurgitation of sour or bitter fluid, especially on bending or lying down
• Chronic dry cough, worse at night
• Hoarseness or a persistent need to clear the throat
• A sensation of a lump in the throat
• Dental erosion
• Chest pain that mimics cardiac pain

Chest pain should never be assumed to be acidity. When it is new, exertional, or accompanied by breathlessness or sweating, it is a cardiac problem until proven otherwise.

What makes it worse

• Large meals, and especially late dinners
• Lying down within three hours of eating
• Excess weight, particularly around the abdomen
• Smoking, which relaxes the sphincter
• Alcohol
• Fried and high-fat food
• Chocolate, peppermint, citrus, tomato, chillies and carbonated drinks in some people
• Certain drugs: calcium channel blockers, nitrates, some asthma medications, NSAIDs
• Tight clothing and belts

The measures that actually work

Lifestyle change has stronger evidence than most people expect, particularly two specific measures:

• Raising the head of the bed by 15-20 cm using blocks under the legs, not extra pillows, which only bend the neck
• A three-hour gap between the last meal and lying down

Weight loss where there is excess weight is the single most effective change. Stopping smoking helps. Eating smaller meals more often reduces pressure.

Medication, and why it stops working

Antacids neutralise acid already present. They work within minutes and wear off within an hour. They are fine for occasional symptoms and useless as a long-term strategy.

H2 blockers such as famotidine reduce acid production for several hours. Tolerance develops within weeks of daily use, which is exactly why people find they stop working.

Proton pump inhibitors such as omeprazole, pantoprazole and esomeprazole are the most effective. Two things about them are widely misunderstood:

• They must be taken 30-60 minutes before a meal, usually breakfast, to work properly. Taken after food or at bedtime they are far less effective.
• They take two to four days for full effect, so they are not rescue medication.

A standard course is four to eight weeks, then a review. Long-term continuous use is appropriate in some conditions but should be a decision, not a drift. Prolonged use has been associated with reduced absorption of vitamin B12, magnesium and calcium, and with an increased risk of certain intestinal infections.

Stopping a PPI abruptly after months causes rebound acid production, which people interpret as the disease returning. Tapering avoids this.

When investigation is needed

Endoscopy is indicated when there are alarm features, or when symptoms persist despite adequate treatment:

• Difficulty or pain on swallowing
• Unintentional weight loss
• Vomiting blood, or black tarry stools
• Persistent vomiting
• Anaemia
• A first presentation after about age 45-50
• Family history of oesophageal or stomach cancer

Long-standing reflux can cause Barrett’s oesophagus, a change in the lining that carries a small risk of cancer and needs surveillance.

When to see a doctor

• Symptoms on more than two days a week for over a month
• Any alarm feature listed above
• Chest pain that could be cardiac
• Reflux that wakes you from sleep
• Needing antacids daily to function

This article is general health information. Persistent reflux should be assessed by a doctor rather than managed indefinitely with over-the-counter medication.