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How Do PPIs Work Differently From Antacids?

Hand holding multiple pills of varying shapes and sizes

Antacids like TUMS and proton pump inhibitors, or PPIs, like Nexium, Prevacid, generic omeprazole, and other similarly named over-the-counter drugs, are typically the first line of defense against mild to moderate acid reflux. These two kinds of medication work differently to achieve a similar result: reducing acid or acidity in the gastric juices, which helps eliminate the burn commonly associated with reflux.

First, before we understand the differences between these two drugs, we must discuss why reflux burns. Gastric juices are very corrosive, and for good reason – they are the first line in breaking down or digesting food and serve to eliminate pathogens that we may ingest through food or drink. The stomach is a very acidic and hostile environment. On the other hand, the esophagus is entirely different, with a soft, sensitive lining that helps push food and drink down into the stomach. Typically, a one-way valve known as a lower esophageal sphincter (LES) allows food and drink to drop into the stomach but closes before gastric juices push back into the esophagus. When the LES starts to lose its normal function and reflux occurs, these juices can cause significant chest and neck pain akin to a burn. Eventually, persistent acid reflux, known as Barrett’s Esophagus, can cause pre-cancerous cellular changes within the esophagus.

As to why it’s called heartburn, this is simply because the typical location of the burn is in the middle of the chest. It has nothing to do with the heart itself.

What Are Antacids, and Do They Work?

Antacids like Tums are typically chalky substances with a slightly alkaline pH that, when consumed, neutralize the acid in the stomach. In other words, they are more of a reactive than a proactive option for reflux symptoms. Most patients take antacids when they first experience reflux and, depending on severity, may experience almost immediate relief. While these are effective, they have limitations, and patients with more chronic acid reflux, also known as GERD, will not enjoy significant or prolonged relief.

Proton Pump Inhibitors, or PPIs

PPIs, on the other hand, are more of a proactive medication for acid reflux, or Gerd. They are indicated for moderate cases of reflux and work by slowing acid production in the stomach’s acid production nodes, known as the proton pumps. As such, while taking these drugs, minimal acid is produced in the stomach.

While this reduces symptoms of GERD, it does not address the core issue, and less acidic but still corrosive gastric juices continue to reflux into the esophagus. Remember, reflux is caused by the inactivation of the lower esophageal sphincter (or being overwhelmed by the upward motion of gastric juices). This does not change after taking over-the-counter medications. To truly reduce the damage caused by chronic reflux, patients should prioritize lifestyle change in the form of improved diet and exercise. This allows for weight loss and consequent reduction in intra-abdominal pressure.

Patients with obesity may also consider a gastric bypass, which, in addition to facilitating weight loss, improves or eliminates reflux in almost all patients. Other options include a fundoplication that wraps the upper portion of the stomach around the lower portion of the esophagus or an implantable bracelet-like device known as the LINX reflux management system. These minimally invasive surgical options reinforce the lower esophageal sphincter by adding appropriate pressure externally.

Next Steps

Patients with acid reflux should know the options available by contacting our office and scheduling a consultation with Dr. Tsuda.