Antacids (usually containing aluminium or magnesium salts) and alginates are commonly used in the management of dyspepsia (also known as indigestion).

Dosage regimen

* 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

* 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 a 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?

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

Side effects

* 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.

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

* 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/AF

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