The best – and worst – medication for acid reflux

Telegraph

21-04-2025

If you've ever reached for a Rennie after dinner you are not alone. Heartburn or acid reflux after a blow out meal is increasingly common. Anyone bothered by this unpleasant condition will be all too familiar with the sour taste and uncomfortable burn from their stomach contents being regurgitated back up their oesophagus and into their throat.
According to the NHS, an astonishing 20 per cent of the adult UK population have problems with severe acid reflux, with rising rates of obesity thought to be behind some of these cases.
In the past decade, Ben Disney, a consultant gastroenterologist at University Hospitals Coventry and Warwickshire NHS Trust, and Nuffield Health has noticed a growing number of patients presenting with symptoms of acid reflux.
'More and more people are becoming obese, and obesity increases abdominal pressure because of the excess weight, meaning that acid will come up more easily,' says Disney.
But this isn't the only cause. While certain foods can exacerbate acid reflux, it can also be triggered by smoking, excess drinking and a condition called hiatus hernia where part of the stomach slides upwards into the chest, pushing it through a hole in the diaphragm. The combination of hormonal changes and a growing baby also mean that pregnant women are also more likely to develop the condition.
Specialists like Cormac Magee, a gastroenterologist at University College London Hospitals NHS Foundation Trust and the Princess Grace Hospital say that it is vital to keep acid reflux under control, because repeated surges of stomach acid can damage the oesophagus over time. This can predispose people to a complication called Barrett's oesophagus where the cell lining begins to grow abnormally, impacting digestion, as well as oesophageal cancer.
'Acid reflux is very common and can be really uncomfortable for patients,' says Magee. 'Medications can be very good at controlling the symptoms and are generally well tolerated. But as with all medications, you want to be on the lowest dose and for the shortest period of time as possible.'
This latter point is particularly key, because while acid reflux medications can play a vital role, they are far from benign. In the last year, various studies have linked long term use of certain proton pump inhibitors (PPIs) – the most widely used class of drugs for severe acid reflux – to worsening symptoms of osteoarthritis and waning cognition, although the evidence for the latter is very mixed.
So let's take a closer look at the most common types of acid reflux drugs, how well they work and the possible risks.
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Antacids
H2 blockers
PPIs
FAQs
Antacids
Pretty much every pharmacy and supermarket comes stocked with Gaviscon, Rennie and Pepto-Bismol, some of the UK's most common brands of antacids. They work by coating the oesophagus with a protective barrier, preventing it from interacting with the stomach acid, and have the advantage of working with near immediate effect. Disney recalls various dinners with friends where someone has had to make a quick post-meal supermarket dash to pick up an emergency bottle of Gaviscon.
'The antacids tend to be very safe for pretty much everyone which is why they're so readily available over the counter,' says Magee.
But at the same time, Dr Semiya Aziz, a north London-based NHS and private GP, points out that these drugs don't address the root cause of the excess acid production or why it's working its way into the oesophagus. Their ingredients, particularly the presence of various minerals or electrolytes, can also initiate side effects if the drugs are taken in excess or over prolonged periods of time. For example, the magnesium within Gaviscon can lead to diarrhoea, while too many Rennie can lead to constipation.
'Due to the ingredients within the antacids, potential electrolyte imbalances or mineral overload may occur, which can have various effects with long-term or excessive use,' says Aziz. 'Lifestyle measures such as dietary changes, avoiding smoking and alcohol must be discussed in any GP consultation [around acid reflux]. This may potentially reduce the necessity for long-term antacids in the first place.'
H2 blockers
First introduced in the late 1970s, H2 blockers like Pepcid and Tagamet were initially considered miracle drugs for their ability to actually decrease the amount of stomach acid produced, and research suggests that they work in around 70 per cent of acid reflux cases.
Nowadays, they are less widely prescribed by specialists because they aren't quite as effective as PPIs, particularly when it comes to tackling severe cases. 'H2 blockers are this older class of medications,' says Disney. 'Before PPIs came around, you'd have patients developing gastric and duodenal ulcers through excess acid, because H2 blockers weren't as effective.'
At the same time, Aziz points out that H2 blockers may actually be a safer option than PPIs for long-term use. However, they aren't completely safe either, especially for people who are taking multiple medications, meaning it's important for anyone considering starting on a H2 blocker to discuss any current and ongoing prescriptions with their GP or specialist.
'Because H2 blockers affect stomach acid levels, they can influence and impair the absorption of other drugs that require an acidic environment,' says Aziz. 'Some H2 blockers affect the activation of blood thinners for example, while others reduce the clearance rates of certain drugs, allowing them to remain in the body for longer periods of time.'
PPIs
Effective in tackling acid reflux in around 90 per cent of cases, PPIs stem from the discovery of enzymes in the stomach lining which are responsible for producing acid. As a result, drugs like omeprazole (known under the brand names Losec, Losec MUPS and Pyrocalm) and esomeprazole (better known as Nexium), target this enzyme activity, diminishing acid production. This reduces the extent to which reflux aggravates the oesophagus and helps it heal.
However in some cases, patients with particularly severe or chronic acid reflux can find themselves taking PPIs for many years or even decades. While specialists are keen to emphasise that PPIs are overall very safe drugs, epidemiological studies have linked their use over this longer timeframe to a range of chronic health conditions.
'Patients on them for a very long time have a slightly increased risk of osteoporosis,' says Magee. 'This is probably because by changing the acidity in the stomach, you have an effect on calcium absorption.'
Aziz also points out that because stomach acid plays a role in absorbing vitamin B12 and the mineral magnesium from food, long-term use of PPIs can lead to deficiencies, while the drugs have also been associated with kidney problems and disruptions to the gut microbiome, including a heightened risk of being infected with the hospital superbug Clostridium difficile.
'Any reduction of acid due to medications may trigger an overgrowth of certain bacteria which may not only be harmful to the gut, but increase the likelihood of various infections in the body,' says Aziz.
Because of these risks, Aziz feels that anyone placed on PPIs for conditions such as mild reflux or ulcers should have a review every two months, reassessing whether or not the medication can be stopped. 'These individuals would ideally be offered a trial period tapering off the PPI, then swapping to a H2 blocker, and finally an antacid,' she says 'Gradual weaning can help individuals come off these medications completely, and avoid long-term use and future complications.'
However, Disney says that some people with particularly severe symptoms, such as Barrett's oesophagus or inflammation of the oesophagus, who likely need to be on PPIs on a lifelong basis. He also feels that some of the risks associated with these drugs have been overstated because the people taking them for a long time have other health conditions.
'A lot of the patients on [long-term] PPIs often have other health problems, such as cardiovascular disease or diabetes,' he says. 'So they're a sicker group of patients, and so they're already more likely to develop things like kidney problems.'
Can you become dependent on acid reflux medications?
One particular condition which has been observed with all acid reflux medications, from antacids to PPIs, is a form of drug dependence known as rebound acid hypersecretion, where patients experience more acid production and stronger reflux symptoms after attempting to cease the drugs.
Disney says that this can be avoided through gradually tapering off the drugs, slowly reducing the frequency of the doses.
'A small proportion of people will get that rebound of excess acid and perhaps have to go back on them,' he says. 'But I'd try and gradually wean off. So if the patient is taking the drugs twice a day, drop down to once a day and then gradually come off them that way.'
Are newer medications coming?
Gastroenterology specialists are also optimistic about a new range of acid reflux treatment options which are starting to emerge. Disney points to an emerging class of medications called potassium-competitive acid blockers (P-CABs) which aren't yet available in the UK, but are already used in the US and Asia.
Some research suggests that P-CABs may be even more effective at treating severe forms of acid reflux and may offer an improved long-term safety profile. 'They're even more effective than PPIs,' says Disney. 'They just haven't come into our market yet.'
Minimally invasive therapies such as endoscopic procedures, some of which use radiofrequency energy to strengthen the muscle that prevents stomach acid from flowing back up into the oesophagus, are also emerging as a different option to long-term medication.
'It needs careful discussion with a clinician and other tests including pH monitoring of the oesophagus,' says Magee. 'But you could potentially reduce or stop medication use with these treatments.'