47: What would you recommend for heartburn?
"Hello. How can I help you?" Amanda asks.
"I want something really effective for indigestion," the young man replies.
"For yourself?"
"That's right."
"You said you want something really effective. Does that mean you've already tried an indigestion remedy?" Amanda asks.
"Yes," the man replies. "I occasionally get indigestion if I overindulge on a night out, but the antacid tablets I keep as a standby have always stopped it before. This time, though, they're not really working."
"So, this time, is the indigestion worse than you usually get?"
"Yes, it's worse and it's different; I think I really went overboard this weekend. I'm getting married next week and I went with my friends to Malta for my stag do. I really overdid it – too much greasy and spicy food and far too much to drink.
"And instead of the vaguely uncomfortable feeling in my stomach that I usually get, this time I've got this horrible burning feeling here." The man puts his hand over the upper part of his chest. "Now and again I get some sort of acidy stuff coming up from my stomach into the back of my throat."
"I think I know what the problem is," says Amanda,
"and I can recommend something that should cure it."
Questions
1 What is the common name for the condition that the young man appears to be suffering, and what are the medical terms for it?
2 What is its cause, and what are the aggravating factors?
3 What type of medicines should you recommend for this condition, and how do they work?
Answers
1 Heartburn. The medical term is gastro-oesophageal reflux disease (GORD), or reflux oesophagitis.
2 Acidic stomach contents coming up (refluxing) from the stomach back into the oesophagus (food pipe). The stomach contracts periodically (peristalsis) to push contents further along the digestive tract. Refluxing is normally prevented by a sphincter, a ring of muscle at the junction of the oesophagus and stomach, which acts like a non-return valve. Its effectiveness can be reduced by one or more of several factors that weaken the muscle, allowing gastric contents to pass back up into the oesophagus. The oesophagus, unlike the stomach lining, has no protection against gastric acid and becomes inflamed, causing the characteristic burning symptoms. Aggravating factors include: some foods and drinks, alcohol, smoking, some drugs, obesity and pregnancy.
3 Antacid/alginate combinations. Antacids work by neutralising the hydrochloric acid produced in the stomach to help digestion of food. The reaction produces carbon dioxide as by-product. Alginates have a sponge-like structure. The carbon dioxide gas bubbles fill the holes in this sponge, making it float like a raft on the top of the stomach contents. When peristalsis occurs, the raft is pushed up against the sphincter and acts as a plug to help prevent refluxing.
The pharmacist's role
One of the most important parts of a pharmacist's role is to check that the medicines prescribed for patients are suitable and safe for them to use. Dee the pharmacist recently spotted a possible problem with a prescription containing a drug for treating GORD.
The patient was a man in his late 60s who had suffered a heart attack about a year before. He was taking digoxin for his heart problem and warfarin to prevent blood clots that could lead to a stroke. He had also been taking ranitidine for some time for GORD, which can become a persistent problem with increasing age. One day the man brought in a repeat prescription and Dee noticed that ranitidine had been replaced by omeprazole (both of these drugs are also available OTC for GORD).
The patient said the ranitidine seemed to be becoming less effective, so he had mentioned this to the nurse when he went for his repeat prescription, and she prescribed omeprazole instead. Dee knew omeprazole can interact with warfarin and increase blood thinning, with a risk of bleeding and haemorrhage, but other drugs in the same group do not have this effect.
Dee suggested to the patient's GP that he might prescribe one of these – lansoprazole – instead. The GP did this and when the man's blood clotting time was checked a couple of weeks later, it was still the same as when he was on ranitidine.
