Symptoms in the Pharmacy :Gastrointestinal Tract Problems(5)
heartburn treatment timescale
If symptoms have not responded to treatment after 1 week the patient
should see a doctor.
Management
The symptoms of heartburn respond well to treatments that are available
OTC, and there is also a role for the pharmacist to offer practical
advice about measures to prevent recurrence of the problem.
Pharmacists
will use their professional judgement to decide whether to offer
antacids/alginates, H2 antagonists or the proton pump inhibitor (PPI)
omeprazole as first-line treatment. The decision will also take into
account customer preference.
Antacids
Antacids can be effective in controlling the symptoms of heartburn
and reflux, more so in combination with an alginate. Choice of
antacid can be made by the pharmacist using the same guidelines as
in the section on indigestion . Preparations that are high
in sodium should be avoided by anyone on a sodium-restricted diet
(e.g. those with congestive heart failure or kidney or liver problems).
Alginates
Alginates form a raft that sits on the surface of the stomach contents
and prevents reflux. Some alginate-based products contain sodium
bicarbonate, which, in addition to its antacid action, causes the release
of carbon dioxide in the stomach, enabling the raft to float on top of
the stomach contents. If a preparation low in sodium is required, the
pharmacist can recommend one containing potassium bicarbonate
instead. Alginate products with low sodium content are useful for
the treatment of heartburn in patients on a restricted sodium diet.
H2 antagonists (cimetidine, famotidine, ranitidine)
Cimetidine, famotidine and ranitidine have been deregulated from
prescription-only control for the short-term treatment (up to 2
weeks) of dyspepsia, hyperacidity and heartburn .
The 2-week treatment limit is intended to ensure that patients do not
continuously self-medicate for long periods. Pharmacists and their
staff can ask whether use has been continuous or intermittent when
a repeat purchase request is made. The H2 antagonists have both a
longer duration of action (up to 8–9 h) and a longer onset of action
than antacids.
Where food is known to precipitate symptoms, the H2 antagonist
should be taken an hour before food. H2 antagonists are also effective
for prophylaxis of nocturnal heartburn. Headache, dizziness, diarrhoea
and skin rashes have been reported as adverse effects but they
are not common.
Manufacturers state that patients should not take OTC cimetidine,
famotidine or ranitidine without checking with their doctor if they are
taking other prescribed medicines.
Cimetidine
Cimetidine can be sold OTC at a maximum dose of 200 mg and
a maximum daily dose of 800 mg. The drug binds to microsomal
cytochrome P450 in the liver and inhibits the normal operation
of the enzyme system, increasing the levels of some drugs. As a result,
cimetidine has a number of significant interactions with other
drugs, including theophylline, resulting in toxic levels of theophylline.
Other important concurrent drugs to avoid are warfarin and
phenytoin. The BNF appendix on drug interactions gives further
information.
Famotidine
Famotidine does not affect the cytochrome P450 system and therefore
does not cause the same range of interactions as cimetidine. The drug
is licensed for OTC use at a maximum dose of 10 mg and a maximum
daily dose of 20 mg. Famotidine is also available as a tablet in combination
with the antacids magnesium hydroxide and calcium carbonate.
The idea behind this is to provide rapid symptom relief from the
antacid and longer action from famotidine.
Ranitidine
Ranitidine is licensed for OTC use in a dose of 75 mg with a maximum
daily dose of 300 mg. Ranitidine does not affect the cytochrome P450
system.
Proton pump inhibitors
Omeprazole was recently deregulated to a P medicine for the relief of
heartburn symptoms associated with reflux in adults. PPIs, including
omeprazole, are generally accepted as being amongst the most effective
medicines for the relief of heartburn. It may, however, take a day or
so for them to start being fully effective. During this period a patient
with ongoing symptoms may need to take a concomitant antacid.
Omeprazole works by suppressing gastric acid secretion in the stomach.
It inhibits the final stage of gastric hydrochloric acid production
by blocking the hydrogen-potassium ATPase enzyme in the parietal
cells of the stomach wall (also known as the proton pump).
Two 10 mg tablets once daily is the initial starting dose. Subsequently,
symptomatic relief from heartburn can be achieved in some
subjects by taking 10 mg once daily, increasing to 20 mg if symptoms
return. The lowest effective dose should always be used and the
maximum daily dose is two tablets. Patients taking omeprazole should
be advised not to take H2 antagonists at the same time. The tablets
should be swallowed whole with plenty of liquid prior to a meal. It is
important that the tablets should not be crushed or chewed. Alcohol
and food do not affect the absorption of omeprazole.
If no relief is obtained within 2 weeks, the patient should be referred
to the doctor. Omeprazole should not be taken during pregnancy or
whilst breastfeeding. Drowsiness has rarely been reported. Treatment
with OTC omeprazole may cause a false negative result in the ‘breath
test’ for helicobacter. Its drug interaction profile is identical to that of
the POM, and the BNF provides detailed information.
Practical points
Obesity
If the patient is overweight, weight reduction should be advised.
There is some evidence that weight loss reduces symptoms of
heartburn.
Food
Small meals, eaten frequently, are better than large meals, as reducing
the amount of food in the stomach reduces gastric distension, which
helps to prevent reflux. Gastric emptying is slowed when there is a
large volume of food in the stomach; this can also aggravate symptoms.
High-fat meals delay gastric emptying. The evening meal is best
taken several hours before going to bed.
Posture
Bending, stooping and even slumping in an armchair can provoke
symptoms and should be avoided where possible. It is better to
squat rather than bend down. Since the symptoms are often worse
when the patient lies down, there is evidence that raising the head of
the bed can reduce both acid clearance and the number of reflux
episodes. Using extra pillows is often recommended but this is not as
effective as raising the head of the bed. The reason for this is that using
extra pillows raises only the upper part of the body, with bending at
the waist, which can result in increased pressure on the stomach
contents.
Clothing
Tight, constricting clothing, especially waistbands and belts, can be an
aggravating factor and should be avoided.
Other aggravating factors
Smoking, alcohol, caffeine and chocolate have a direct effect by
making the oesophageal sphincter less competent by reducing its
pressure and therefore contribute to symptoms. The pharmacist is in
a good position to offer advice about how to stop smoking, offering a
smoking cessation product where appropriate .
The knowledge that the discomfort of heartburn will be
reduced can be a motivating factor in giving up cigarettes.
Heartburn in practice
Case 1
Mrs Amy Beston is a woman aged about 50 who wants some advice
about a stomach problem. On questioning, you find out that sometimes
she gets a burning sensation just above the breastbone and that
she feels the burning in her throat, often with a bitter taste as if some
food has been brought back up. The discomfort is worse when in bed
at night and when bending over whilst gardening. She has been having
the problem for 1 or 2 weeks and has not yet tried to treat it. Mrs
Beston is not taking any medicines from the doctor. To your experienced
eye this lady is at least a stone overweight. You ask Mrs Beston
if the symptoms are worse at any particular time and she says they are
worst shortly after going to bed at night.
The pharmacist’s view
This woman has many of the classic symptoms of heartburn; pain in
the retrosternal region and reflux. The problem is worse at night after
going to bed, as is common in heartburn. Mrs Beston has been experiencing
the symptoms for about 2 weeks and is not taking any medicines
from the doctor.
It would be reasonable to advise the use of an alginate antacid
product about 1 h after meals and before going to bed, or an H2
antagonist. Practical advice could include the tactful suggestion that
Mrs Beston’s symptoms would be improved if she lost weight. Advice
on healthy eating and contact with a local Weight Watchers group
could be given. Mrs Beston could also try raising the head of the bed
or using extra pillows at bedtime, wearing loose-fitting clothes, cutting
down on tea, coffee and, if she smokes, on smoking.
This is a long list of potential lifestyle changes. It might be a good
idea to explain the contributory factors to Mrs Beston and negotiate
with her as to which one she will begin with. Success is more likely to
be achieved and sustained if changes are introduced one at a time.
Menopausal women are more prone to heartburn, and weight gain
at the time of the menopause will exacerbate the problem.
The doctor’s view
The advice given by the pharmacist is sensible. Acid reflux is the most
likely explanation for her symptoms. It is not clear from the presentation
whether she was seeking medication or simply asking for an
opinion about the cause of her symptoms, or both. It is always helpful
to explore a patient’s expectations in order to produce an effective
outcome to a consultation. In this instance the interchange between
the pharmacist and Mrs Beston is complex as a large amount of
information needs to be given, both explaining the cause of the symptoms
(providing an understandable description of oesophagus, stomach,
acid reflux and oesophagitis) and advising about treatment and
lifestyle. It is often sensible to offer a follow-up discussion to check on
progress and reinforce advice. If her heartburn was not improving it
would provide an opportunity to recommend referral to her doctor.
The doctor’s next step would be very much dependent on this
information. If a clear story of heartburn caused by acid reflux were
obtained, then reinforcement of the pharmacist’s advice concerning
posture, weight, diet, smoking and alcohol would be appropriate. If
medication was requested, antacids or alginates could be tried. If the
symptoms were severe, an H2 antagonist or omeprazole would be
treatment options. In the case of persistent symptoms or diagnostic
uncertainty, referral for endoscopy would be necessary. Helicobacter
pylori eradication is not thought to play a role in the management of
heartburn.
Case 2
You have been asked to recommend a strong mixture for heartburn for
Harry Groves, a local man in his late fifties who works in a nearby
warehouse. Mr Groves tell you that he has been getting terrible
heartburn for which his doctor prescribed some mixture about
1 week ago. You remember dispensing a prescription for a liquid
alginate preparation. The bottle is now empty and the problem is no
better. When asked if he can point to where the pain is, Mr Groves
gestures across his chest and clenches his fist when describing the pain,
which he says feels heavy. You ask whether the pain ever moves and
Mr Groves tells you that sometimes it goes to his neck and jaw. Mr
Groves is a smoker and is not taking any other medicines. When asked
if the pain worsens when bending or lying down, Mr Groves says it
does not, but he tells you he usually gets the pain when he is at work,
especially on busy days.
The pharmacist’s view
This man should see his doctor immediately. The symptoms he has
described are not those that would be typical of heartburn. In addition,
he has been taking an alginate preparation, which has been
ineffective. Mr Groves’ symptoms give cause for concern; the heartburn
is associated with effort at work and its location and radiation
suggest a more serious cause.
The doctor’s view
Mr Groves’ story is suggestive of angina. He should be advised to
contact his doctor immediately. The doctor would require more details
about the pain, such as duration and whether or not the pain can come
on without any exertion. If the periods of pain were frequent, prolonged
and unrelieved by rest it would be usual to arrange immediate
hospital admission as the picture sounds like unstable or crescendo
angina.
If an urgent inpatient referral is not required, the doctor would
carry out a fuller assessment that would usually include an examination,
electrocardiogram (ECG) , urine analysis and blood test. This in
turn could lead to medication, e.g. aspirin or glyceryl trinitrate (GTN),
possibly a long-acting nitrate (isosorbide mononitrate), perhaps a
beta-blocker and/or calcium channel blocker being prescribed and an
urgent outpatient referral to a cardiologist. Mr Groves would be
strongly advised to stop smoking.
More detailed tests are likely to be arranged in hospital. These
would probably include an exercise cardiogram and an angiogram.
This latter test allows visualisation of the blood vessels supplying
the heart muscle and assessment of whether surgery would be
advisable.
If symptoms have not responded to treatment after 1 week the patient
should see a doctor.
Management
The symptoms of heartburn respond well to treatments that are available
OTC, and there is also a role for the pharmacist to offer practical
advice about measures to prevent recurrence of the problem.
Pharmacists
will use their professional judgement to decide whether to offer
antacids/alginates, H2 antagonists or the proton pump inhibitor (PPI)
omeprazole as first-line treatment. The decision will also take into
account customer preference.
Antacids
Antacids can be effective in controlling the symptoms of heartburn
and reflux, more so in combination with an alginate. Choice of
antacid can be made by the pharmacist using the same guidelines as
in the section on indigestion . Preparations that are high
in sodium should be avoided by anyone on a sodium-restricted diet
(e.g. those with congestive heart failure or kidney or liver problems).
Alginates
Alginates form a raft that sits on the surface of the stomach contents
and prevents reflux. Some alginate-based products contain sodium
bicarbonate, which, in addition to its antacid action, causes the release
of carbon dioxide in the stomach, enabling the raft to float on top of
the stomach contents. If a preparation low in sodium is required, the
pharmacist can recommend one containing potassium bicarbonate
instead. Alginate products with low sodium content are useful for
the treatment of heartburn in patients on a restricted sodium diet.
H2 antagonists (cimetidine, famotidine, ranitidine)
Cimetidine, famotidine and ranitidine have been deregulated from
prescription-only control for the short-term treatment (up to 2
weeks) of dyspepsia, hyperacidity and heartburn .
The 2-week treatment limit is intended to ensure that patients do not
continuously self-medicate for long periods. Pharmacists and their
staff can ask whether use has been continuous or intermittent when
a repeat purchase request is made. The H2 antagonists have both a
longer duration of action (up to 8–9 h) and a longer onset of action
than antacids.
Where food is known to precipitate symptoms, the H2 antagonist
should be taken an hour before food. H2 antagonists are also effective
for prophylaxis of nocturnal heartburn. Headache, dizziness, diarrhoea
and skin rashes have been reported as adverse effects but they
are not common.
Manufacturers state that patients should not take OTC cimetidine,
famotidine or ranitidine without checking with their doctor if they are
taking other prescribed medicines.
Cimetidine
Cimetidine can be sold OTC at a maximum dose of 200 mg and
a maximum daily dose of 800 mg. The drug binds to microsomal
cytochrome P450 in the liver and inhibits the normal operation
of the enzyme system, increasing the levels of some drugs. As a result,
cimetidine has a number of significant interactions with other
drugs, including theophylline, resulting in toxic levels of theophylline.
Other important concurrent drugs to avoid are warfarin and
phenytoin. The BNF appendix on drug interactions gives further
information.
Famotidine
Famotidine does not affect the cytochrome P450 system and therefore
does not cause the same range of interactions as cimetidine. The drug
is licensed for OTC use at a maximum dose of 10 mg and a maximum
daily dose of 20 mg. Famotidine is also available as a tablet in combination
with the antacids magnesium hydroxide and calcium carbonate.
The idea behind this is to provide rapid symptom relief from the
antacid and longer action from famotidine.
Ranitidine
Ranitidine is licensed for OTC use in a dose of 75 mg with a maximum
daily dose of 300 mg. Ranitidine does not affect the cytochrome P450
system.
Proton pump inhibitors
Omeprazole was recently deregulated to a P medicine for the relief of
heartburn symptoms associated with reflux in adults. PPIs, including
omeprazole, are generally accepted as being amongst the most effective
medicines for the relief of heartburn. It may, however, take a day or
so for them to start being fully effective. During this period a patient
with ongoing symptoms may need to take a concomitant antacid.
Omeprazole works by suppressing gastric acid secretion in the stomach.
It inhibits the final stage of gastric hydrochloric acid production
by blocking the hydrogen-potassium ATPase enzyme in the parietal
cells of the stomach wall (also known as the proton pump).
Two 10 mg tablets once daily is the initial starting dose. Subsequently,
symptomatic relief from heartburn can be achieved in some
subjects by taking 10 mg once daily, increasing to 20 mg if symptoms
return. The lowest effective dose should always be used and the
maximum daily dose is two tablets. Patients taking omeprazole should
be advised not to take H2 antagonists at the same time. The tablets
should be swallowed whole with plenty of liquid prior to a meal. It is
important that the tablets should not be crushed or chewed. Alcohol
and food do not affect the absorption of omeprazole.
If no relief is obtained within 2 weeks, the patient should be referred
to the doctor. Omeprazole should not be taken during pregnancy or
whilst breastfeeding. Drowsiness has rarely been reported. Treatment
with OTC omeprazole may cause a false negative result in the ‘breath
test’ for helicobacter. Its drug interaction profile is identical to that of
the POM, and the BNF provides detailed information.
Practical points
Obesity
If the patient is overweight, weight reduction should be advised.
There is some evidence that weight loss reduces symptoms of
heartburn.
Food
Small meals, eaten frequently, are better than large meals, as reducing
the amount of food in the stomach reduces gastric distension, which
helps to prevent reflux. Gastric emptying is slowed when there is a
large volume of food in the stomach; this can also aggravate symptoms.
High-fat meals delay gastric emptying. The evening meal is best
taken several hours before going to bed.
Posture
Bending, stooping and even slumping in an armchair can provoke
symptoms and should be avoided where possible. It is better to
squat rather than bend down. Since the symptoms are often worse
when the patient lies down, there is evidence that raising the head of
the bed can reduce both acid clearance and the number of reflux
episodes. Using extra pillows is often recommended but this is not as
effective as raising the head of the bed. The reason for this is that using
extra pillows raises only the upper part of the body, with bending at
the waist, which can result in increased pressure on the stomach
contents.
Clothing
Tight, constricting clothing, especially waistbands and belts, can be an
aggravating factor and should be avoided.
Other aggravating factors
Smoking, alcohol, caffeine and chocolate have a direct effect by
making the oesophageal sphincter less competent by reducing its
pressure and therefore contribute to symptoms. The pharmacist is in
a good position to offer advice about how to stop smoking, offering a
smoking cessation product where appropriate .
The knowledge that the discomfort of heartburn will be
reduced can be a motivating factor in giving up cigarettes.
Heartburn in practice
Case 1
Mrs Amy Beston is a woman aged about 50 who wants some advice
about a stomach problem. On questioning, you find out that sometimes
she gets a burning sensation just above the breastbone and that
she feels the burning in her throat, often with a bitter taste as if some
food has been brought back up. The discomfort is worse when in bed
at night and when bending over whilst gardening. She has been having
the problem for 1 or 2 weeks and has not yet tried to treat it. Mrs
Beston is not taking any medicines from the doctor. To your experienced
eye this lady is at least a stone overweight. You ask Mrs Beston
if the symptoms are worse at any particular time and she says they are
worst shortly after going to bed at night.
The pharmacist’s view
This woman has many of the classic symptoms of heartburn; pain in
the retrosternal region and reflux. The problem is worse at night after
going to bed, as is common in heartburn. Mrs Beston has been experiencing
the symptoms for about 2 weeks and is not taking any medicines
from the doctor.
It would be reasonable to advise the use of an alginate antacid
product about 1 h after meals and before going to bed, or an H2
antagonist. Practical advice could include the tactful suggestion that
Mrs Beston’s symptoms would be improved if she lost weight. Advice
on healthy eating and contact with a local Weight Watchers group
could be given. Mrs Beston could also try raising the head of the bed
or using extra pillows at bedtime, wearing loose-fitting clothes, cutting
down on tea, coffee and, if she smokes, on smoking.
This is a long list of potential lifestyle changes. It might be a good
idea to explain the contributory factors to Mrs Beston and negotiate
with her as to which one she will begin with. Success is more likely to
be achieved and sustained if changes are introduced one at a time.
Menopausal women are more prone to heartburn, and weight gain
at the time of the menopause will exacerbate the problem.
The doctor’s view
The advice given by the pharmacist is sensible. Acid reflux is the most
likely explanation for her symptoms. It is not clear from the presentation
whether she was seeking medication or simply asking for an
opinion about the cause of her symptoms, or both. It is always helpful
to explore a patient’s expectations in order to produce an effective
outcome to a consultation. In this instance the interchange between
the pharmacist and Mrs Beston is complex as a large amount of
information needs to be given, both explaining the cause of the symptoms
(providing an understandable description of oesophagus, stomach,
acid reflux and oesophagitis) and advising about treatment and
lifestyle. It is often sensible to offer a follow-up discussion to check on
progress and reinforce advice. If her heartburn was not improving it
would provide an opportunity to recommend referral to her doctor.
The doctor’s next step would be very much dependent on this
information. If a clear story of heartburn caused by acid reflux were
obtained, then reinforcement of the pharmacist’s advice concerning
posture, weight, diet, smoking and alcohol would be appropriate. If
medication was requested, antacids or alginates could be tried. If the
symptoms were severe, an H2 antagonist or omeprazole would be
treatment options. In the case of persistent symptoms or diagnostic
uncertainty, referral for endoscopy would be necessary. Helicobacter
pylori eradication is not thought to play a role in the management of
heartburn.
Case 2
You have been asked to recommend a strong mixture for heartburn for
Harry Groves, a local man in his late fifties who works in a nearby
warehouse. Mr Groves tell you that he has been getting terrible
heartburn for which his doctor prescribed some mixture about
1 week ago. You remember dispensing a prescription for a liquid
alginate preparation. The bottle is now empty and the problem is no
better. When asked if he can point to where the pain is, Mr Groves
gestures across his chest and clenches his fist when describing the pain,
which he says feels heavy. You ask whether the pain ever moves and
Mr Groves tells you that sometimes it goes to his neck and jaw. Mr
Groves is a smoker and is not taking any other medicines. When asked
if the pain worsens when bending or lying down, Mr Groves says it
does not, but he tells you he usually gets the pain when he is at work,
especially on busy days.
The pharmacist’s view
This man should see his doctor immediately. The symptoms he has
described are not those that would be typical of heartburn. In addition,
he has been taking an alginate preparation, which has been
ineffective. Mr Groves’ symptoms give cause for concern; the heartburn
is associated with effort at work and its location and radiation
suggest a more serious cause.
The doctor’s view
Mr Groves’ story is suggestive of angina. He should be advised to
contact his doctor immediately. The doctor would require more details
about the pain, such as duration and whether or not the pain can come
on without any exertion. If the periods of pain were frequent, prolonged
and unrelieved by rest it would be usual to arrange immediate
hospital admission as the picture sounds like unstable or crescendo
angina.
If an urgent inpatient referral is not required, the doctor would
carry out a fuller assessment that would usually include an examination,
electrocardiogram (ECG) , urine analysis and blood test. This in
turn could lead to medication, e.g. aspirin or glyceryl trinitrate (GTN),
possibly a long-acting nitrate (isosorbide mononitrate), perhaps a
beta-blocker and/or calcium channel blocker being prescribed and an
urgent outpatient referral to a cardiologist. Mr Groves would be
strongly advised to stop smoking.
More detailed tests are likely to be arranged in hospital. These
would probably include an exercise cardiogram and an angiogram.
This latter test allows visualisation of the blood vessels supplying
the heart muscle and assessment of whether surgery would be
advisable.
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