Acid Reflux

Treatment usually starts with a proton pump inhibitor at an appropriate dose and duration, alongside practical changes to timing of meals, alcohol and sleeping position.

Book if

• Heartburn or regurgitation is happening regularly
• You are buying antacids or omeprazole every week
• Symptoms are disturbing your sleep
• Something you were prescribed has stopped working

Urgent — needs endoscopy, not acid suppression

• Difficulty or pain swallowing
• Unintentional weight loss
• Persistent vomiting, or vomiting blood
• Black tarry stools
• New indigestion starting over the age of 55
• A lump in the abdomen

These need investigation quickly. Treating them with a PPI masks the symptom and delays diagnosis.

Emergency — call 999

Chest pain with breathlessness, sweating, or pain radiating to the arm or jaw. Heart attacks are mistaken for indigestion regularly, and the consequences of getting it wrong in that direction are severe.

1. Rule out the serious

Reflux shares symptoms with things that are not reflux. This comes first, always.

2. Treat the acid

A proton pump inhibitor at full dose for four to eight weeks, then review. Not indefinitely by default.

3. Test for H. pylori

A treatable bacterial cause of persistent indigestion, and easily missed.

4. Practical changes that work

Nothing to eat within three hours of bed. Raise the head of the bed rather than adding pillows. Alcohol, late meals and weight are the three biggest levers.

5. Review, do not just repeat

Long-term PPI use reduces absorption of magnesium, B12 and calcium. It should be a decision, not a default.

Four to eight weeks, then a decision

A proton pump inhibitor is prescribed at full dose for four to eight weeks and then reviewed — not repeated indefinitely by default.

• Days 1–4 — PPIs take a few days to reach full effect, unlike antacids. An antacid alongside helps in that window
• Weeks 4–8 — review, and the decision about stepping down
• Then — the lowest dose that controls symptoms, or on-demand use, rather than automatic continuation

Long-term use should be a decision

Long-term PPI use reduces absorption of magnesium, vitamin B12 and calcium, and is associated with a modest increase in fracture risk and in C. difficile infection.

None of that means PPIs are dangerous or that anyone who needs one should stop — for Barrett's oesophagus or severe oesophagitis, long-term treatment is clearly right. It means the decision should be revisited rather than assumed.

Stepping down

Stopping abruptly after months causes rebound acid, which feels like the reflux returning worse than before. It is not — it settles in a couple of weeks, and knowing that in advance is what stops people restarting unnecessarily.

Halve the dose for two weeks, then alternate days, with an antacid for breakthrough.

Test for H. pylori

A treatable bacterial cause of persistent indigestion, and easily missed. Eradication resolves symptoms for a significant number of people and reduces ulcer and stomach cancer risk.

Stop the PPI for two weeks before testing — taking one makes the test falsely negative, which is a common cause of a missed diagnosis.

Urgent — endoscopy, not acid suppression

• Difficulty or pain swallowing, or food sticking
• Unintentional weight loss
• Persistent vomiting, or vomiting blood
• Black tarry stools
• New indigestion starting over 55
• A lump in the abdomen, or anaemia

Treating any of these with a PPI masks the symptom and delays diagnosis, which is the specific harm to avoid here.

Call 999

Chest pain with breathlessness, sweating, or pain radiating to the arm or jaw. Heart attacks are mistaken for indigestion regularly, and the consequences of getting it wrong in that direction are severe. Antacids relieving it proves nothing.

The three biggest levers, and none is a prescription

• Nothing to eat within three hours of lying down. The single most effective change for night-time symptoms
• Raise the head of the bed by 10–20cm — blocks under the legs or a wedge under the mattress. Extra pillows do not work, because they bend you at the waist and raise abdominal pressure
• Weight, particularly around the middle, which raises pressure on the valve. Even modest loss helps measurably

Alongside: alcohol, especially in the evening; smoking, which weakens the valve directly; and your own trigger foods — typically coffee, chocolate, fat, spice, citrus and mint. Cut what actually affects you rather than the whole list.

Medication, cheapest first

• Antacids and alginates — over the counter, and alginates taken after meals and at bedtime are genuinely effective, forming a raft over the stomach contents. Under-used
• Famotidine, an H2 blocker, over the counter and useful for night-time symptoms
• Omeprazole and esomeprazole are available over the counter for short-term use
• Prescription PPIs at full dose for four to eight weeks

Look for something else if it does not respond

Reflux that does not respond to adequate treatment is often not reflux. Worth considering:

• H. pylori, which is treatable and easily missed
• Coeliac disease, which needs testing before removing gluten — the test is unreliable if you have already cut it out
• Functional dyspepsia or IBS
• Gallstones, cardiac pain, and medication — NSAIDs, bisphosphonates, some blood pressure medicines and doxycycline all cause this
• Anxiety, which genuinely amplifies visceral symptoms

Where endoscopy is the answer

Any red flag, symptoms not responding to adequate treatment, or long-standing reflux where Barrett's oesophagus should be considered.

NHS referral is free, and urgent pathways exist for exactly these symptoms.

What does not have good evidence

Apple cider vinegar, alkaline water, and "gut healing" supplement protocols. Also elimination diets started before coeliac testing, which make the test unreliable and can cost you the diagnosis.

What you pay us

• £40 for the consultation, of which the red flag screening is the most valuable part
• H. pylori and coeliac testing where indicated, quoted first
• £40 for review at four to eight weeks

What you pay the pharmacy

PPIs are among the cheapest prescriptions there are — generic omeprazole and lansoprazole cost very little. We earn nothing from what is prescribed.

What you can buy without any appointment

• Antacids and alginates, which are genuinely effective and under-used — taken after meals and at bedtime
• Famotidine, useful for night-time symptoms
• Omeprazole and esomeprazole, available over the counter for short-term use

If you have simple heartburn and no warning symptoms, a pharmacist can sort you out for a few pounds. We would rather say so.

So what is worth paying for?

The screening, and it is the whole point. Reflux shares symptoms with several things that are not reflux, and the specific harm here is treating a warning symptom with a PPI and delaying a diagnosis.

Also: H. pylori testing, which is treatable and easily missed; a plan with a defined endpoint rather than an indefinite repeat; and help stepping down from long-term treatment.

The free things that matter most

Not eating within three hours of bed. Raising the head of the bed. Reducing alcohol and weight. These outperform most prescriptions for night-time reflux and cost nothing.

Where not to spend money

• Branded antacids when own-brand is identical
• Apple cider vinegar, alkaline water and "gut healing" supplements
• Private endoscopy before asking about the NHS route, which is free and has urgent pathways for exactly these symptoms

How do I know it is reflux and not my heart?

You often cannot, and that is precisely why this matters. Heart attacks are mistaken for indigestion regularly.

Call 999 for chest pain with breathlessness, sweating, or pain radiating to the arm or jaw — particularly if it comes on with exertion.

An antacid relieving it proves nothing. The cost of being wrong in that direction is not worth the embarrassment of being wrong in this one.

Which symptoms mean I need an endoscopy?

Difficulty or pain swallowing, food sticking, unintentional weight loss, persistent vomiting or vomiting blood, black tarry stools, anaemia, or new indigestion starting over 55.

These need investigating rather than treating. A PPI settles the symptom and delays the diagnosis, which is the specific harm to avoid.

Should I be on omeprazole long term?

Sometimes yes — but it should be a decision, not a default.

For Barrett's oesophagus or severe oesophagitis, long-term treatment is clearly right. For ordinary reflux, the aim is the lowest dose that controls symptoms, or on-demand use, reviewed periodically.

Is long-term PPI use harmful?

The honest answer: there are associations rather than proven harms, and they are modest.

Reduced absorption of magnesium, B12 and calcium, a small increase in fracture risk, and increased C. difficile risk. Nobody who genuinely needs a PPI should stop because of this — but it is a reason to review rather than repeat automatically.

Every time I stop, it comes back worse. Am I dependent on it?

Not dependent — but there is a real explanation. Rebound acid hypersecretion follows stopping a PPI abruptly after prolonged use, and it feels exactly like the reflux returning worse than before.

It settles within about two weeks. Step down gradually — halve the dose for a fortnight, then alternate days, with an antacid for breakthrough.

What is H. pylori and should I be tested?

A bacterium that causes persistent indigestion and ulcers, and it is treatable with a course of antibiotics. Eradication resolves symptoms for many people and reduces ulcer and stomach cancer risk.

Stop your PPI two weeks before testing — taking one causes a false negative, which is a common reason it gets missed.

Do extra pillows help?

No, and they can make it worse — they bend you at the waist and raise abdominal pressure.

Raise the whole head of the bed by 10–20cm with blocks under the legs, or use a wedge under the mattress. It is one of the most effective things for night-time symptoms.

Which foods should I cut out?

Only the ones that actually affect you. Coffee, chocolate, fat, spice, citrus, mint and alcohol are the usual suspects, but blanket elimination is miserable and unnecessary.

Timing matters more than content: nothing within three hours of lying down.

The tablets are not working. What now?

Then it may not be reflux, and that is worth pursuing rather than escalating the dose.

Worth considering: H. pylori, coeliac disease, functional dyspepsia, gallstones, cardiac pain, anxiety, and medication — NSAIDs, bisphosphonates, doxycycline and some blood pressure medicines all cause this.

Should I cut out gluten to see if it helps?

Not before being tested for coeliac disease. The test becomes unreliable once you have stopped eating gluten, and people lose the diagnosis this way — which matters, because coeliac disease has consequences well beyond symptoms.

Test first, then experiment.

What is Barrett's oesophagus?

A change in the lining of the oesophagus from long-standing reflux, which slightly raises the risk of oesophageal cancer and is followed with periodic endoscopy.

It is a reason to take long-standing reflux seriously, and a reason long-term treatment is clearly right for some people rather than something to step down from.