It has been almost 2 years since ranitidine was withdrawn from the UK market, and across the globe, yet ranitidine alternative drugs are still in demand. UK Ranitidine (Zantac) was a popular medication purchased over the counter and prescribed for the symptoms of indigestion / acid reflux, both of which are formally known as gastro-oesophageal reflux disease (GORD).
Ranitidine discontinued in 2019
In the UK and US, ranitidine was subject to many recalls at the end of 2019 and the beginning of 2020 due to possible contamination with N-Nitrosodimethylamine (NDMA), a probable human carcinogen (a chemical that possibly causes cancer). Withdrawal of ranitidine affected the lower strength of 75mg tablets, which were available over the counter without a prescription, and prescription-only ranitidine, a higher strength of 150mg and 300mg tablets.
Ranitidine drug classification
Ranitidine belongs to a group of medicines called H2-receptor antagonists, commonly known as H2-blockers. H2-blockers are one group of medicines that suppress acid production in the stomach.
What are H2-receptor antagonists?
- H2 – a type of receptor located in the stomach lining.
- Receptor – a molecule that has the role of ‘a port’ to which other molecules, including drugs, bind (connect).
- An antagonist is a chemical or drug which binds to a receptor and stops some biological action from happening. Ranitidine binds to a receptor and reduces the production of the stomach.
Ranitidine alternative drugs: legal classification
Over the counter or prescription-only medications (POMs) which can be used as an alternative to ranitidine belong to one of the following groups:
- (other) H2-receptor antagonists (prescription-only medicines)
- Proton pump inhibitors (PPIs) for example omeprazole or esomeprazole
The legal classification of ranitidine alternative drugs:
- Over the counter options, formally known as General Sale List (GSL) items. GSL products can be sold in any retail outlets such as supermarkets, shops, etc.
- Pharmacy-only medicines (P) are only available from pharmacies or online pharmacies that operate under the supervision of a pharmacist.
- Prescription-only medicines (POMs) – available only on prescription, written by a doctor or any other qualified prescriber.
Ranitidine alternative drugs: over the counter options
Over the counter H2-receptor antagonist
In the UK, ranitidine was the only H2-receptor antagonist available over the counter. Since the withdrawal from the market, none of the other H-2 blockers is available without a prescription.
Over the counter Proton Pump Inhibitors (PPIs) as an alternative to ranitidine
Some PPIs are available to buy without a prescription from the pharmacy (P) or simply off the shelf in supermarkets or other retail outlets (GSL).
PPIs are more effective than H2-receptor antagonists such as ranitidine in the reduction of acid production. However, they are associated with the possibility of more common side effects and a number of drug interactions with other medicines.
All over the counter PPIs have similar licenced use and recommendations on the duration of treatment:
- All PPIs available without prescription are licensed for adults aged 18+
- Over the counter PPIs ad are generally used in the short-term management of heartburn / acid reflux.
- If symptoms do not resolve within 14 days of the treatment with over the counter PPIs, patients are advised to speak to their GP.
- For all PPIs, some patients may need to take the medication for 2-3 days before improvement in symptoms is seen; usually, however, patients may experience relief from symptoms on day 1. Nevertheless, over the counter PPIs are not advertised as products for the immediate release of heartburn symptoms.
Common side effects associated with the use of PPIs:
- Upset stomach: diarrhoea, constipation, flatulence (wind)
- Vomiting (being sick) or nausea (feeling sick)
- Formation of benign polyps in the stomach
Over the counter omeprazole as an alternative to ranitidine
1. Omeprazole 20mg gastro-resistant tablets
Omeprazole is available as a pharmacy-only medication in the form of 20mg gastro-resistant tablets. Large pharmacy chains mainly sell omeprazole 20mg under their brand name, for example, Boots Acid Reflux 20 mg Gastro-Resistant Tablets (Boots Pharmacy). Independent pharmacies may sell Numark Heartburn and Acid Reflux Gastro-Resistant, which contain 20mg of omeprazole. Packs of 7 and 14 tablets are usually available.
Dose: The recommended dose is 20mg daily for up to 14 days.
2. Pyrocalm Control (Omeprazole 20mg gastro-resistant tablets)
Available as a GSL product, each Pyrocalm Control tablet contains 20mg of omeprazole. Pyrocalm Control was launched in 2019, and it is still a relatively new product. Not all pharmacies or supermarkets stock it; however, it can easily be purchased online. Pyrocalm Control comes in two box sizes with 7 or 14 tablets.
Availability: GSL medication (any retail outlet or website, supermarkets, and pharmacies)
Dose: 1 tablet taken once daily for a recommended maximum of 14 days.
Over the counter esomeprazole medicines alternative to ranitidine
The main active ingredient of the next two products is esomeprazole. Like omeprazole, esomeprazole is a proton pump inhibitor (PPI). Similarly, patients may need to take esomeprazole for 2-3 consecutive days to control their symptoms, although a single dose of esomeprazole may provide relief from symptoms of acid reflux. If no improvement in symptoms is seen within two weeks despite the treatment with esomeprazole, patients need to speak to their GP.
3. Nexium Control (Esomeprazole 20mg capsules or tablets)
Nexium Control is a well-known brand of over the counter PPI due to extensive marketing campaigns on Tv. Nexium Control contains esomeprazole as an active ingredient. A single dose of Nexium Control can settle the symptoms of heartburn for up to 24 hours.
Nexium Control is widely available with most supermarkets and pharmacies stocking this product. It can also be bought online from different websites, including Amazon.co.uk.
Nexium Control comes in the form of capsules and tablets, available in two different pack sizes of 7 and 14 tablets. Nexium Control capsules are advertised as Nexium Control Mini-Capsules due to their much smaller size than tablets. Produces of Nexium Control capsules inform that capsules are 53% smaller than the tablet (based on the volume of the capsule vs. the tablet).
What is the difference between omeprazole and esomeprazole?
Omeprazole and esomeprazole are related drugs. In a pain language esomeprazole is a ‘mirror imge‘ of omeprazole. Enantiomers (the chemical name for mirror images of molecules/drugs) have the same chemical structure, but different arrangements of atoms. Drugs which exist as enantiomers may have the same actions in the body, but now always. Omeprazole and esomeprazole have the same mechanism of action.
Availability: GSL (any retail outlet or website, supermarkets, and pharmacies)
Dose: the recommended dose is one capsule/tablet per day
4. Guardium Acid Reflux Control (Esomeprazole 20mg gastro-resistant tablets)
Guardium Acid Reflux Control contains esomeprazole as an active ingredient. It is the latest addition of esomeprazole-containing products available without a prescription in the UK. Guardium Acid Reflux Control can be purchased online. Like all other previous PPIs available over the counter, Guardium Acid Reflux Control is also classified as a GSL medicine, which is available in supermarkets and pharmacies. Guardium Acid Reflux Control is promoted as a product ‘from the makers of Gaviscon’, a popular brand of a wide range of antacid medications used in the symptomatic management of heartburn.
Guardium Acid Reflux Control comes in a pack size of 7 and 14 tablets.
Availability: GSL (any retail outlets or websites, supermarkets, and pharmacies)
Dose: the recommended dose is one tablet (20mg of esomeprazole) per day for up to two weeks.
5. Pantoloc Control (Discontinued)
The last on the list of ranitidine alternative drugs is Pantoloc. Pantoloc contains 20mg of pantoprazole. Pantoprazole is classieief as PPI. Pantoloc Control has been withdrawn from the European market and is no longer available as over the counter medication. Pantoprazole 20mg and 40mg tablets are still available as a prescription-only medication.
Ranitidine alternatives UK prescription-only medicines
Prescribed H2-receptor antagonists
There are few options when it comes to H2-receptor antagonists available on prescription.
Since the withdrawal of ranitidine, famotidine became more commonly prescribed. Prescriptions issued for famotidine skyrocketed from under 1000 pre-ranitidine withdrawals to over 140000 in recent months.
Famotidine belongs to the same class of drugs as ranitidine and has the same mechanism of action. The advantage of famotidine another h2-blocker cimetidine is less interaction with other drugs.
Famotidine comes in form of tablets, 20mg and 40mg tablets.
Nizatidine is another prescription-only h2-blocker which is a ranitidine alternative. Although there has been an increase in the number of prescriptions issued for nizatidine, overall this h2-blocker is much less prescribed than famotidine.
Nizatidine comes in form of capsules, 150mg and 300mg capsules.
Cimetidine is the least commonly prescribed h2-blocker. Cimetidine is not commonly prescribed as it interacts with many other drugs. Cimetidine affects how other medications are absorbed (how much drug gets into the body), their metabolism (how much medication is changed into the active form in the body), and elimination (how much drug leaves the body). With many potential interactions with other drugs, cimetidine became an obsolete choice in the management of gastro-oesophageal reflux disease (GORD).
9. Prescrioption-only Omeprazole
Prescribed omeprazole is available in different formulations, including:
- Omeprazole gastro-resistant tablets
- Omeprazole gastro-resistant capsules
- Omeprazole dispersible tablets
- Omeprazole liquid
Additionally, tablet and capsule forms of omeprazole exist in the following strengths: 10mg, 20mg, and 40mg.
Omeprazole liquid is classified as a special product in the UK. It is made on an individual basis for each patient. Omeprazole became the first choice when PPIs are considered in the treatment due to its low cost and effectiveness.
Related post: Omeprazole alternative drugs for indigestion.
Lansoprazole is the second most prescribed PPI in the UK. Lansoprazole is available in the form of 15mg and 30mg capsules and orodispersible tablets. When prescribed, orodispersible formulations (brand name: Zoton FasTab) are commonly used in patients with swallowing difficulties or in children. Orodispersible tablets dissolve in the mouth when placed on the tongue.
Esomeprazole is available in form of capsules and tablets, available as 20mg and 40mg preparations. Esomeprazole can be prescribed as a generic medication or as Nexium. The latter is not commonly prescribed due to the price difference between generic versions of esomeprazole and Nexium.
Pantoprazole on prescription comes only in the form of tablets. 20mg and 40mg of pantoprazole drug are available. Pantoprazole is not commonly prescribed in the NHS.
Similarly to pantoprazole, rabeprazole is not commonly prescribed. Rabeprazole comes in form 10mg and 20mg gastro-resistant tablets.
There is no evidence to suggest one PPI is better than another. However, when PPIs are prescribed for the treatment of GORD, for example, patients may be switched between PPIs if one fails to produce a satisfactory response (NICE, 2017).
Ranitidine alternative drugs: Conclusion
When it comes to short-term management of heartburn / acid reflux, patients have a good choice of drugs, which are available without a prescription. Five different proton pump inhibitors are available over the counter from a pharmacy, with three being licensed as general sale items, which can be purchased from any retail outlet.
Patients who have been experiencing symptoms of heartburn for longer than two weeks (despite PPI treatment) should speak to their GP. Additional symptoms highlighted by manufacturers of PPIs that needed a referral include:
- as weight loss (for no reason)
- repeated episodes of sickness
- difficulties in swallowing
- blood present in the vomit or faeces
- repeated episodes of indigestion
- presence of new or recently changed symptoms in patients who are 55 and over
- presence of pain or lump in the stomach
- Omeprazole Alternative Drugs BEST for Acid Reflux
- Omeprazole liquid – cost & availability
- Nexium Control review
NICE (2022). Dyspepsia – proven GORD. Available at: https://cks.nice.org.uk/dyspepsia-proven-gord Accessed on 09/12/2022
OpenPrescribing.net (2022), EBM DataLab, University of Oxford, 2017. Prescribing information for H2-receptors anatagonist. Available at: https://openprescribing.net/chemical/ Accessed on 09/12/2022