tee replied: "The reason it says not to buy a second pack is that if you need a second pack it suggests a long term or more serious problem that usually requires a medical opinion, if only to confirm that it is indeed only heartburn and that he is ok to carry on taking it if it is working for him."

W W D replied: "The only real difference between IV and PO is for people who can't take PO, as those who are actively vomiting. None of these seems to affect GI bleeding, but the H2 blockers seem to be a pretty good adjuvant treatment for allergic problems like hives and are occasionally used to premedicate in, as an example, IV contrast radiography where there's a risk of anaphylactoid reactions, as part of a cocktail. PPI's, of course, don't make sense in these applications. Some people also use them to decrease gastric acidity pre-operatively as a prophylactic for reflux/aspiration."

Raza replied: "Acid Reflux Relief : Combination Therapy Most patients treated with PPIs in conventional dosages do not exhibit complete suppression of stomach acid secretion. Approximately 70% of individuals who take a PPI twice a day experience nocturnal stomach acid breakthrough (defined as a stomach pH lesser than 4 for more than 1 hour at night). Brief episodes of acid reflux occur frequently during these breakthrough periods in patients with GERD. For some patients taking a PPI twice daily, nocturnal acid breakthrough can be abolished by adding a histamine H2-receptor blocker at bedtime. It is not clear that this approach is desirable, however. Complete elimination of acid reflux usually is not necessary to effect the healing of reflux esophagitis. Indeed, most patients who are treated with a PPI in conventional dosage exhibit complete healing of their symptoms and signs of GERD. No clear clinical benefit yet has been demonstrated for the practice of adding a histamine H2-receptor blocker at bedtime to PPI therapy. A few older investigations have explored the value of combination drug therapy for the healing of GERD. The great efficacy of the PPIs used as single agents in this condition has discouraged investigators from undertaking new studies on combination therapy. Drug combinations that have been studied have included an H2 blocker plus either sucralfate or a prokinetic agent. Cimetidine (1200 mg/d) combined with sucralfate (5 g/d) was found to be superior to cimetidine alone for relieving daytime heartburn and for improving the endoscopic signs of esophagitis. For patients unresponsive to treatment with cimetidine alone, the addition of metoclopramide resulted in symptomatic improvement significantly more often than the addition of placebo, but side effects of metoclopramide were frequent. A combination of ranitidine (300 mg/d) plus metoclopramide (40 mg/d) was not found to be as effective as omeprazole alone (20 mg/d) in healing the signs and symptoms of esophagitis. Some studies explored combination therapy with the prokinetic agent cisapride, but these studies are of historical interest only because cisapride has been withdrawn from general use due to serious side effects (lethal arryhythmias). For patients with moderately severe reflux esophagitis, the use of combination therapy may eliminate the need for treatment with a PPI. However, the addition of a second medication increases the cost of therapy and the potential for side effects. Furthermore, the long-term benefit of combination therapy has not been demonstrated. For patients who are refractory to single-agent therapy (with an H2 blocker, sucralfate, or a prokinetic), a change to a PPI generally is more likely to effect healing than the addition of a second drug. Acid reflux relief is therefore a broad term that covers all the measures used to control symptoms and signs of acid reflux disease. Normally, the lower esophageal sphincter remains closed except during swallowing. This prevents the passage of food and acid from the stomach into the esophagus. If the lower esophageal sphincter becomes weakened or relaxed, stomach acid may back up into the esophagus. Frequent acid reflux can irritate and inflame the lining of the esophagus, causing symptoms and signs of acid reflux. A better understanding of relief would thus entail knowledge of some aspects of normal structure and function, so that changes in the disease and its control could be easily considered. Actually acid reflux relief involves both preventive and curative measures, and in addition to treatment; orientation with the causes, symptoms and complications of acid reflux are essential for proper management. Acid reflux relief includes: dietary changes,lifestyle modifications, specific medications and surgical operations.Basic knowledge of the underlying causes and progression of acid reflux and answering frequently asked questions about its relief; add to the depth of understanding. 2. Antacids Antacids are a class of medications that act by directly neutralizing gastric acid. The use of antacids dates back to the ancient Greeks, who used ground coral powder (calcium carbonate) as a remedy for dyspepsia. Calcium carbonate (TumsR) is still a commonly used antacid, as is magnesium hydroxide (MylantaR, MaaloxR), and magnesium hydroxide with or without calcium (RolaidsR). Powdered sodium bicarbonate is also available, but is less frequently used. Antacids provide rapid, but temporary, relief of heartburn (lasting 30 to 60 minutes) and thus may require frequent dosing. The few well-designed studies evaluating antacids in the treatment of GERD have generated conflicting results. Several trials have shown no significant difference between antacids and placebo in the control of heartburn,6 whereas others demonstrate a clear improvement of symptoms with antacid therapy.7, 8 No trials, however, have proven antacids to be effective in the healing of erosive esophagitis. Currently, anta"