With all these drugs to choose from, how do doctors decide which is the right acid reflux treatment for you? This is where the ‘guidelines’ from NICE (the National Institute for Clinical Excellence) are so helpful.

NICE recommends either a ’step up’ or a ’step down’ approach, depending on the severity of your acid reflux disease. There are 5 five levels, starting with the mildest treatment (antacids/alginates) through H2 antagonists, to rising doses of PPIs. For example, if endoscopy has shown that you have ulcers in your esophagus or Barren’s esophagus, you will start on the highest ‘healing’ dose of a PPI - level 5. The dose can eventually be cut down once the symptoms have improved, to a level that continues to keep you symptom-free.

On the other hand, if you have mild symptoms and no need for endoscopy, you may be started on level 1, with an antacid-alginate combination and advised on lifestyle. If this does not work, your doctor may add an H2 antagonist - level 2.

Depending on your progress after that, you will pass up or down the scale. All patients should have their own ‘treatment plan’ that guides them on how to manage their own symptoms, and this can often be stopped when their esophagus eventually heals and the symptoms disappear.

However, the fact that you are able to stop the treatment doesn’t mean that you can now stop going to your doctor.

Most people with gastro-esophageal reflux disease (GERD) require long term management. The guiding principle for long term management is to step down to the treatment that is least costly but still effective in controlling your GERD and acid reflux symptoms.

Finding the right level of management may take time in some patients. Patients returning with a relapse after a trial without treatment should be restarted on the initially successful therapy and then have treatment stepped down as appropriate. For patients who require only intermittent short courses of antisecretory (acid-lowering) therapy, it may be more effective to give a proton pump inhibitor at full dose than to titrate treatment up from either half dose of PPI or a standard dose of H2 receptor antagonist.

By optimizing the treatment in these ’steps’, endoscopy is kept to a minimum. If a particular acid reflux treatment successfully controls a patient’s symptoms, the doctor can be assured that the esophagitis has healed, and there is no need for further endoscopies.

Even when the patient needs to continue on long-term PPIs because of severe esophagitis (Los Angeles stages (C) and (D)), repeat endoscopy is not always needed, as it is safe to assume that if the GERD symptoms are absent, the esophagitis has healed. On the other hand, patients in these categories must have repeat endoscopies if they still have symptoms despite standard daily doses of PPIs.

The groups of patients who must be kept on continuous treatment include:

Patients with ulcers in the esophagus that have been induced by an NSAID and who have no choice but to continue with it because they have chronic pain (such as from arthritis). They should remain on maintenance doses of PPIs (level 4).

Patients with severe GERD, such as Barren’s esophagus or an endoscopy-proven ulcer, should also remain on maintenance doses of a PPI (level 4).

Patients whose very severe acid reflux disease has been complicated in the past by stricture, ulcers and hemorrhage should be left on full doses of PPIs (level 5).

‘Prokinetic’ drugs, designed to speed up the passage of food from stomach to duodenum, such as metoclopramide (Maxolon, Gastro-bid) can be added, if needed, to help prevent bloating.

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One form of acid reflux remedy that you are probably already aware of, but may not understand fully how they work are acid suppressant drugs. These drugs act on the acid-producing mechanisms within the stomach wall, so that they greatly reduce the amount of acid inside the stomach. This is a more effective acid reflux relief as it eases the symptoms for most people with moderate to severe esophagitis than antacid combinations.

Cimetidine (Tagamet) was the first of this group of acid reflux remedies. It revolutionized the treatment of gastric and duodenal ulcers, but it was marginally less successful when tried against reflux esophagitis. Patients taking it in the early trials found that their symptoms were much less, but endoscopy appearances showed that they still had a moderate degree of inflammation in the esophagus.

The early doses were possibly too low, and many people with acid reflux disease have to take double the original dose of 400 mg to keep their symptoms at bay.

Ranitidine (Zantac) is another H2 receptor antagonist. It is similar in effect to cimetidine, and the usual dose is 300 mg each evening. The dose can be raised up to as much as 1500 mg daily for added benefit, although most doctors would prefer not to go so high, and use another acid reflux treatment, probably a proton pump inhibitor, instead.

Newer H2 antagonists include famotidine (Pepcid) and nizatidine (Axid). They are similar in action to cimetidine and ranitidine, with little to choose between them.

All drugs, including these GERD and acid reflux remedies, may produce side-effects, and acid-suppressant drugs are no exception. H2 receptor antagonists should be used with caution in people with liver or kidney problems or who are pregnant or breast feeding. They may ‘mask’ the symptoms of stomach cancer, so if you have one or more of the ‘alarm’ symptoms your specialist will rule out stomach cancer before prescribing one.

Side-effects of this group of drugs are relatively rare, but they include diarrhea, headache, dizziness, rash and tiredness. Much rarer are effects on the heart rhythm, on the bone marrow and occasional reports of enlarged breasts in men (gynaecomastia) and impotence.

Cimetidine has a disadvantage compared with other drugs in this group, in that it interacts with drugs that use the same type of mechanism in the liver for their breakdown. So it cannot be taken alongside warfarin (an anti-clotting drug), phenytoin (for epilepsy) or theophylline (for asthma).

The other drugs in this group may be taken instead.

Proton pump inhibitors

Proton pump inhibitors (PPIs) act on the acid-producing mechanism at an earlier stage in the process than H2 antagonists, so that they completely eradicate acid, rather than reduce it, from the stomach contents.

The first PPI was omeprazole (Losec). It has since been joined by esomeprazole (Nexium), lansoprazole (Zoton), pantoprazole (Protium) and rabeprazole (Panel).

As with the H2 antagonists, PPIs are so efficient in removing symptoms in reflux disease, even when it is severe, that they can ‘mask’ a stomach cancer. When a person shows ‘alarm features’ the specialist team must rule out a stomach or esophageal cancer before prescribing them.

Side-effects of PPIs are similar to those of the H2 antagonists. The patient leaflet for PPIs list alt the side-effects that have been reported: they look horrendous, but it must be remembered that they are all very rare. Most people find these acid reflux remedies easy to tolerate and that they have no side-effects. However, it is important to read the leaflet, so that if a problem does arise, you can tell what it is, and deal with it accordingly.

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Happily, drugs do work as a cure for acid reflux and GERD. There are five groups of different acid reflux treatments listed in order of efficacy.

GERD and acid reflux treatments:

1. Antacids and alginates.
2. H2 receptor antagonists (such as ranitidine and cimetidine).
3. ‘As needed’ doses of proton pump inhibitors (such as omeprazole and lansoprazole),
4. Maintenance low-dose proton pump inhibitors.
5. Healing high-dose proton pump inhibitors.

Remedies For Acid Reflux - Antacids and Alginates

Antacids describe themselves. They are alkaline based remedies for acid reflux, designed to neutralize the acid produced by the stomach. Alginates are derived from seaweed (agar) and are designed to release a gel into the lower esophagus that will protect the surface from acid attack, or act as a ‘raft’ that floats on the top of the stomach contents and prevent the upward flow into the esophagus. Both types of treatment, especially
if given together, are effective for mild to moderate GERD and acid reflux disease.

Antacids are usually aluminum or magnesium compounds. They range in convenience and cost - the cheaper preparations tending to be less palatable than, but just as effective as the dearer ones. They can all be bought from pharmacies to save you having to wait for a prescription.

The basic antacid style of remedies for acid reflux are aluminum hydroxide and magnesium carbonate or trisilicate. Pharmacies have dozens of formulations of them to suit your taste and preference. Co-magaldrox is a mixture of aluminum and magnesium hydroxides, marketed as Maalox or Mucogel.

Remedies for acid reflux which contain  aluminum and magnesium compounds are poorly soluble in water, and act for a long time if they remain in the stomach. The main difference between them is that aluminum-containing antacids tend to constipate and magnesium compounds tend to loosen the motions, so combining them, in theory, minimizes these effects on the bowel.

If you need a longer action, you can choose a combination of an antacid with an alginate. The sticky alkaline barrier that they form on the top of the stomach contents combines neutralization of the acid with the raft principle mentioned above. Among alginate-containing products are Algicon, Gastrocote, Gaviscon, Peptac, Rennie Duo and Topal. There are many more.

An alternative acid reflux treatment to alginate is a silicone, such as simeticone, (dimeticone). This is a ‘de-foaming’ agent that is thought to make it easier to belch, reduce bloating, and allow faster passage of food and digestive juices through the stomach, reducing reflux as it does so. It is particularly useful in easing hiccups. Antacid-simeticone preparations include Altacite Plus, Asilone and Maalox Plus. Again, there are many others.

All antacid-alginate or antacid-simeticone combinations of acid reflux treatments are popular over-the-counter drugs, so they must work for many people. If you find one that suits you, you may as well stick to it. However, if you have to take one every day, you need to step up your treatment into the acid-suppressant drugs, the H2 receptor antagonists or the proton pump inhibitors.

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According to the many studies on acid refluc disease and GERD, more than 80 per cent of sufferers smoke, many of them heavily. That in itself makes a point - as fewer than 30 per cent of those in most developed countries now smoke, there must be a strong link between smoking and acid reflux.

Smoking is a suicidal habit for anyone, no matter how healthy they seem. It is even worse, if that is possible, for people with acid reflux and GERD, because it irritates the already inflamed esophagus and prevents it healing.

It narrows the already compromised circulation to the affected area of esophagus, something you absolutely can’t afford to happen, as it increases the risk of a hemorrhage or a perforation from it. Worst of all, smoking increases the acid production in the stomach and damages the mucosal protective barrier of mucus.

In every way, even smoking one or two cigarettes a day will reduce your chances of dealing successfully with GERD. So if you are a smoker, you must become a non-smoker before you can cure acid reflux.

How, exactly, does being a smoker harm you?

Tobacco smoke contains carbon monoxide and nicotine. The first poisons the red blood cells, so that they cannot pick up and distribute much-needed oxygen to the organs and tissues, including the heart muscle. Carbon monoxide-affected red cells (in the 20-a-day smoker, nearly 20 per cent of red cells are carrying carbon monoxide instead of oxygen) are also stiffer than normal, so that they can’t bend and flex through the smallest blood vessels. The gas also directly poisons the heart muscle, so that it cannot contract properly and efficiently, thereby delivering a ‘double whammy’ of damage to it.

Nicotine causes small arteries to narrow, so that the blood flow through them slows. It raises blood cholesterol levels, thickening the blood and promoting degeneration in artery walls. Both nicotine and carbon monoxide encourage the blood to clot, multiplying the risks of coronary thrombosis and stroke.

Add to all this the tars that smoke leaves in the lungs, which further reduce the ability of red cells to pick up oxygen, and the scars and damage to the lungs that always in the end produce chronic bronchitis and sometimes induces cancer, and you have a formula for disaster.

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There are several natural treatments for acid reflux disease, GERD and heartburn that are also very simple and can provide a long term solution to the condition. Here’s some of the more effective ones:

Losing weight

If you can exercise easily without bringing on a cough or wheezing, do so. The best way is to find an exercise that you enjoy (cycling, swimming, brisk walking, ballroom dancing - it doesn’t matter as long as you are likely to stick to it), and do it for at least half an hour, preferably an hour, on three or four days a week.

It should be brisk enough to make you breathless, without causing you distress. If you can manage this regimen, you will find that you can lose a pound or two each week - and that amounts to 50 pounds a year! If this is combined with eating smaller amounts, it will ease your discomfort from an over-full stomach and decrease the pressure inside the abdomen that tends to push your stomach contents upwards, causing the acid reflux and heartburn symptoms.

The secret of losing weight by eating less is to eat slowly. Most fat people tend to wolf down their food, taking 15 minutes or less to polish off a large meal at home. If they could spread the time to more than half an hour, they would eat a lot less. Try it – you could be pleasantly surprised.

The reason for this is that once we feel hungry, it takes about half an hour for the feeling to die down, no matter how much we eat (within reason). If we eat our main meals round a table, having conversation with friends and family, eating slowly and waiting between courses, the feeling of satiety (fullness) starts in around half an hour, regardless of how much we have eaten (provided, of course, we have eaten something!). So if we eat slowly enough, we feel full before we have eaten a large amount, and we lose weight.

A lot of families seem to have abandoned this habit of eating around the family table, and we face a huge problem of obesity. The French eat as they have always done, taking their time and savoring every bite. Go to Paris and try to spot an obese adult - he or she is much more likely to be a tourist than a local. The French are far less affected by the obesity plague than we are.

Which foods?

The second point is that it doesn’t really matter, within reason, what food you eat. People with digestive problems often ask which foods cause their symptoms and which are unlikely to do so. They are surprised to find that there are very few types of food that cause GERD or acid reflux symptoms. A minority of sufferers find that fried foods upset them: others find that tea or coffee or similar hot drinks do so.

Many more rue the glass of spirits that well-meaning friends have offered them. The rule about food is that if you find one that brings on heartburn or discomfort, then avoid it. Everyone is different. It is more important to eat a variety of foods that don’t obviously induce the symptoms rather than to go on a restrictive diet. You will almost certainly find, as you change from big meals to small portions eaten slowly, that you return to eating foods that in the past you thought made you feel ill. This is why I’m not devoting a big section in this blog dedicated to diets. They don’t work in GERD, except in so far as you will find by trial and experience which foods suit you and which ones don’t.

Sleeping position

The third point is about raising the head of the bed. Of course, it is meant to keep the upper body semi-upright, to avoid reflux passing horizontally from stomach to esophagus. I’ve found in practice that all it does is to make people slide down the bed while they sleep so that they end up curled up, flat on the mattress.

That is no advantage to them, and can result in a disturbed night. So I would add that if you are going to raise the bed head, do it by only 2 or 3 inches, and put a foot-plate at the bottom of the bed, so you can’t slip downwards.

To be frank, raising the bed doesn’t often help: if you really have to keep upright overnight, you may well find that sleeping in an easy chair with a back and side arms is more effective.

Once your lifestyle changes have started to improve your heartburn symptoms, you can then return to bed, using two or three pillows to keep your body at a reasonable angle from the horizontal.

Smoking

This point is a very serious one. Smoking has such a bad effect on GERD that I felt that it deserved a separate article to itself - acid reflux causes - smoking. If you smoke, then you need to read the smoking related articles on this site. Stopping smoking is the best thing you can do for your health and probably the best natural treatments for acid reflux disease there is (if you’re a smoker).

If you don’t smoke, at least let relatives or friends who smoke read it, because the message to stop is just as much a general one as it is specifically aimed at GERD.

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The first priority the doctor has in finding a suitable acid reflux treatment (or GERD treatment) is to reassure you that you have every chance that the symptoms will ease and even disappear. You, though, have your part to play in your own treatment by changing your lifestyle, and your doctor will help by supporting you with some acid reflux remedies.

Once treatment starts, you should also be reassured that you don’t have an illness that is life-threatening. Many people with GERD and acid reflux disease are frightened that they may have cancer or heart disease: once your diagnosis has been made clear you can cast these worries aside and get on with your life, content in the knowledge that GERD can be cured.

Once you understand that, you are already treating yourself and the cure has started before you have swallowed your first dose of whatever acid reflux medication you are taking.

The wrong lifestyle has played its part in most people with GERD, and changing to a healthier lifestyle is the first step towards finding your cure for acid reflux. The guidelines on lifestyle for GERD include:

• Lose excess weight.
• Stop smoking.
• Reduce alcohol intake if it is above two standard drinks (of wine) a day.
• Raise the head of the bed at night and use plenty of pillows (to try to stay reasonably upright when asleep).
• Eat small meals often, rather than one large meal at any time.
• Avoid hot drinks.
• Avoid alcohol and food less than three hours before going to bed at night (to avoid a full stomach when lying horizontal).
• Avoid drugs that may affect the normal peristalsis of the esophagus or the sphincter (nitrates, anticholinergics, tricyclic antidepressants).
• Avoid drugs that may damage the esophageal mucosa (NSAIDs, potassium salts, bisphosphonates).

So by making some simple lifestyle changes and working with your doctor, you should be able to find some natural acid reflux treatments that will cure acid reflux disease for good.

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There are many pieces to our lifestyle that could be listed under GERD and acid reflux causes,  and the good news is that most of them can be easily managed to help reduce or even eliminate completely your acid reflux symptoms.

Alcohol

I’m sorry to sound a killjoy, but if you have acid reflux disease or GERD, you must be very careful about your alcohol consumption. The neater the alcohol you drink, the more likely you are to provoke an attack of acute GERD. So, although as a lover of Malt Whiskey, it pains me to write this, ease off on the spirits. Confine yourself to the odd glass of wine, preferably with meals. That’s how the French approach alcohol, and it’s very civilized. They have less GERD than we do.

Clothing

Not all acid reflux and GERD sufferers are the same. Some can tolerate coffee or fatty foods, others can’t. Being overweight and eating large meals are certainly one of the main causes of acid reflux and GERD, and so is pregnancy (but at least that’s only a short term state).

Tight clothes can put pressure on the abdomen, so that if I were writing this book a generation ago, I would have mentioned corsets. However, I’m reliably informed (by my slim wife) that women no longer squeeze into restrictive clothing – they just ‘let it all hang out’. Any tight band across the middle, such as a belt, may induce acid reflux symptoms. I leave it to the individual woman (or man) to judge whether or not that is a factor in their GERD.

Medication

Some prescription drugs can contribute to GERD by causing the sphincter at the cardia to relax. They include the ‘tricyclics’ used to treat depression. They are usually easily spotted, because their generic name (seen in small print under the trade name) often ends in  -amine  or  -ine.  Among them are amitriptyline, amoxapine, clomipramine, imipramine, lofepramine, nortriptyline and trimipramine.

‘Anticholinergic’ or ‘atropine-like’ drugs prescribed to treat bowel spasms or irritable bowel syndrome can do their job only too well and relax the gastro esophageal sphincter, too. They include dicyclomine (also called dicycloverine), hyoscine and propantheline bromide.

Atropine sulphate tablets are given on prescription but are also available over-the-counter, mainly as Actonorm powder, which is a mixture of atropine, aluminum, calcium carbonate, magnesium, sodium bicarbonate and peppermint oil. This, too, can relax the gastro esophageal sphincter and provoke attacks of GERD symptoms.