Dyspepsia (also known as indigestion) is very common, and is the term used to describe a collection of symptoms including heartburn, burping and bloating. It may be due to an underlying condition, such as gastro-oesophageal disease (GORD), peptic or duodenal ulcer, pregnancy or hiatus hernia, but it can also be a symptom of something more serious, such as stomach or oesophageal cancer. It may also be a side effect of medication, but often no cause can be found.

Treatments differ, according to the underlying condition, but the main drugs used to treat dyspepsia are proton pump inhibitors (PPIs; lansoprazole, omeprazole, esomeprazole, pantoprazole, rabeprazole), H2-antagonists (ranitidine, famotidine, nizatidine, cimetidine) antacids (usually containing aluminium or magnesium salts) and alginates. Other drugs that may be used including antibiotics to eradicate H pylori, a bacteria present in some ulcers.

Dosage regimen

* PPIs are taken once daily in the morning, unless the patient is taking split doses to reduce side-effects. They are best taken regularly to prevent symptoms.

* H2-antagonists are usually taken twice daily, but nizatidine and famotidine are taken at night. Once daily doses are best taken at night. They are best taken regularly to prevent symptoms.

* Antacids and alginates should be taken after eating. However, they should not be taken immediately prior to lying down because there is a risk of disrupting the alginate layer. Antacid-alginates can be taken as required.

Patient's knowledge of medicine use

* Regular acid suppression is advised where symptoms persist, but at the lowest dose for symptom control. If symptoms stop with PPI treatment and do not return on cessation the treatment can be used only when symptoms appear. However, the patient should be warned that PPIs take time to start working (maximum effect is achieved after four days with omeprazole, for example) and that an antacid-alginate treatment may be required at first.

* Is the patient taking any other medications whose absorption is affected by concurrent acid-suppression, such as tetracyclines or iron? At least two hours should elapse between taking acid suppression treatments and any conflicting medication.

* If the patient has a stomach ulcer, explain how H pylori and NSAIDs contribute to peptic ulcer, and how acid suppression and eradication help with symptoms.

Is the medication working

* Is the patient taking an antacid-alginate regularly in addition to their PPI or H2-antagonist? This points to either sub-optimal symptom control, or a lack of understanding that both need not be taken.

* Ask about symptom changes that may require investigation, such as blood in the stools.

* Ask if there has been any sudden symptom change which could point towards gastric cancer which is slightly more common in peptic ulcer disease.

* Enquire whether the patient may still be taking medications capable of exacerbating symptoms, such as nifedipine or NSAIDs, or medications that lower oesophageal sphincter tone?

* If symptoms are still being experienced after four weeks of H pylori treatment, refer the patient to their GP.

* Ask whether there are underlying factors, such as depression or stress, that may be exacerbating symptoms

Side effects

* PPIs commonly cause GI disturbances, headache and dizziness.

* H2-antagonists commonly cause GI disturbances, headache, dizziness, rash and tiredness.

* Antacids containing bismuth can cause the stools to darken in colour.

Monitoring

* Ask the patient if they have had an H pylori test if an ulcer is suspected. The test is easily performed and can avoid endoscopy.

* Enquire when was the last GP review took place. Annual reviews are advised with long-term dyspepsia treatment.

* Check the patient is not still taking treatment rather than maintenance doses of PPI past the recommended guideline times, and if so investigate whether this is clinically necessary.

* Where treatment has not produced a change in symptoms, has a change of dose been tried?

* Check for interactions with other medications, especially cimetidine, which has a cytochrome p450 metabolic pathway.

* Review medications such as nitrates that have their own general gastric side-effects.

* In patients taking antacids, check whether they are suitable for patients with concurrent diseases that may be present, such as heart disease and diabetes. Many contain large amounts of sodium and sugar, or are mainly calcium-based. Low sodium products contain less than 1mmol per tablet or 10ml dose. Gaviscon Advance is suitable in both heart disease and diabetes.

Lifestyle

* Tell patients that simple lifestyle measures such as healthy eating, weight reduction and smoking cessation may improve symptoms, as may avoiding precipitating factors such as alcohol, coffee, and spicy, fatty and rich foods.

* Eating frequent small meals ensures the stomach is neither over-full, or empty for long periods of time, and may aid symptoms.

* Raising the head of the bed by about four to six inches and eating the last meal about three hours before bed can also help.

Rosemary Blackie, community pharmacist, Wicker Pharmacy, Sheffield

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