Fire in the Belly Heartburn is more than an inconvenience. Which treatments put out the fire?
(MONEY Magazine) – Some 60 million Americans regularly endure the characteristic burning sensation commonly known as heartburn. Twenty-five million of them suffer every day. Now more than ever, heartburn--also known as acid reflux disease--is in the news. One reason: The Food and Drug Administration recently issued a warning about dangerous interactions between Propulsid, a powerful reflux fighter, and other drugs. Another reason: an alarming rise in the incidence of esophageal cancer, which is linked to chronic heartburn.
Once, people thought they should grin and bear heartburn. Today, most people are aware that several treatments, ranging from lifestyle changes to drugs to surgery, can douse heartburn's fire. Sales of the popular prescription drug Prilosec, for example, rose 24% in 1999 to $5.9 billion.
Chronic acid reflux is usually the result of a weakened valve at the top of the stomach called the lower esophageal sphincter. When it's functioning properly, the sphincter allows food and water to pass into the stomach but prevents the stomach's highly acidic contents from coming out. When it's weak, acid can back up into the esophagus. Over time, the esophagus may become inflamed, a condition called reflux esophagitis.
In some instances, such as pregnancy, heartburn is not serious. But for those who experience it regularly--more than twice a week--it is cause for concern. Symptoms of severe reflux disease or GERD (gastroesophageal reflux disease) may include hoarseness, difficulty swallowing and weight loss. GERD may also complicate asthma. Left untreated, GERD can morph into a more serious condition known as Barrett's esophagus, increasing the risk of esophageal cancer. Contrary to what you may expect, when the condition worsens, heartburn symptoms may improve. "When the esophagus is damaged, heartburn symptoms tend to diminish," says Dr. Joel E. Richter, chairman of gastroenterology at the Cleveland Clinic. "So if you've ever suffered from persistent heartburn, you need to see a doctor."
A GERD exam often includes an endoscopy, which takes 15 to 30 minutes. While the patient is sedated and given local anesthesia, a specialist inserts a tube into the esophagus to check for inflammation. The good news is that if caught early, chronic heartburn is easy to treat. Only 5% to 10% of those diagnosed with GERD have the cellular changes that indicate Barrett's esophagus. Here's what MONEY learned about treatment options for heartburn.
It's possible a few new habits are all you need. Try cutting out heartburn's chief culprits: caffeine, chocolate, alcohol, nicotine, mints and fried food. If you're overweight, you'll benefit from shedding some pounds. Nighttime heartburn victims should try eating dinner at least three hours before going to bed. Wearing comfortable clothing and adjusting your bed to elevate the torso may also bring relief; you can place a pair of specially designed plastic fixtures called BedBlox under the head of your bed. Previously available only through doctors' offices and HMOs, a set of BedBlox costs $39.95 and now can be ordered online at www.bedblox.com.
If antacids like Tums, Mylanta and Maalox don't help, try an H2 blocker: These drugs, which include Tagamet HB 200, Zantac 75 and Pepcid AC, work by reducing stomach-acid production. H2 blockers are more effective than antacids and can be taken before meals to prevent heartburn. However, they take longer to start working than conventional antacids. Combination antacid and H2 blocker drugs are now being reviewed by the FDA. Their advantage: The antacid would offer instant relief, giving the H2 blocker time to act.
Costs: About 14[cents] per dose for ant-acids, 30[cents] for H2 blockers
Concerns: Antacids that contain magnesium (such as Maalox, Mylanta) can cause diarrhea; aluminum-based products (Amphogel) can cause constipation. Self-treatment over a long period of time can delay a proper diagnosis.
Prescription-strength H2 blockers are twice as powerful as their over-the-counter versions. But another type of acid fighter called a proton pump inhibitor is considered the more potent therapy. The best-known PPIs are Prilosec and Prevacid. They work by inhibiting stomach cells' acid production. "PPIs are expensive, but they offer the fastest relief--plus help heal the esophagus," says Dr. Richter.
Promotility agents--Reglan and the controversial drug Propulsid--are used for severe heartburn. They work by hastening the emptying of stomach contents into the intestine.
Costs: Approximately $100 a month for PPIs, $95 a month for Propulsid and $22 for Reglan
Concerns: PPIs have been used in the U.S. for only 10 years, so their long-term effects are unknown--and many people take them for life. The FDA has linked Propulsid to 70 fatalities. Most of those who died had heart disease or were taking Propulsid along with other medications. "The FDA warning seriously limits the use of this drug," says Dr. Stuart Spechler, chief of gastroenterology at the VA center in Dallas. Reglan, the other promotility option, can cause unpleasant side effects, such as abnormal muscle reactions and drowsiness.
Individuals with severe heartburn who would otherwise have to take medication for the rest of their lives may prefer to have surgery, particularly if they're under age 50. The procedure, called fundoplication, wraps the upper part of the stomach around the esophagus to increase pressure on the esophageal sphincter and keep acid in the stomach. Typically, a surgeon makes an incision in the chest or abdomen, but a new laparoscopic procedure is significantly less invasive. A laparoscopic fundoplication requires an overnight stay in the hospital, says Dr. Michael D. Holzman, assistant professor of surgery at Vanderbilt University Medical Center. The 10-year success rate is 80% to 90%. Experimental techniques using an endoscope--so there's no incision--await FDA approval.
Cost: About $8,000, which is covered by most health insurance plans
Concerns: The open procedure has a long, often painful recovery period. Complications may include flatulence and bloating. Choosing a surgeon experienced with the procedure is crucial.