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Ask the expert: indigestion and heartburn

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Get to grips with the causes of these symptoms, and how to treat them.

A glance around any pharmacy is enough to remind you of the wide range of indigestion and heartburn remedies available. So it’s hardly surprising that customers can easily get confused.

It is estimated that 40% of the adult population experiences indigestion each year. Those affected face the choice between seeing their GP or visiting a pharmacy to self-treat their symptoms.

This means you and your staff have a key role helping patients understand their symptoms, and the treatment options on offer. 

The expert: Dr Ayesha Akbar

Traditionally, heartburn [refers to] the burning sensation when acid is coming back up to the mouth, and retrosternal burning, which is burning behind the chest. The indigestion-type feeling is bloating, abdominal discomfort and the feeling of food sitting in the stomach and not going down after a meal. Some patients will complain of having one symptom, both, or an overlap between different symptoms.

Dr Akbar is a consultant and member of the British Society of Gastroenterology

Symptoms and causes

Acid is produced naturally in the stomach as part of the digestive process. However, excessive amounts of acid can irritate the stomach lining, causing the inflammation and discomfort associated with indigestion. If the stomach acid makes its way up the throat – in a process called reflux – it can cause the irritation commonly referred to as heartburn.

The table of symptoms and causes (see right) can help you quickly identify which condition the patient has, and help you decide the best treatment available.

As you can see, there are a number of overlapping causes that can result in both indigestion and heartburn. It is therefore important to spend time with each patient so that you can determine the precise cause of their individual symptoms.

Prevention

Although indigestion and heartburn may only be short-lived, they can still both cause distress. There is a range of recommendations you and your team can provide customers to help them reduce or prevent the symptoms of both conditions, depending on the patient’s lifestyle:

  • Reduce their body weight, if they are obese
     
  • Lower the amount of fat in their diet
     
  • Avoid trigger foods
     
  • Avoid caffeine and alcohol
     
  • Stop late-night eating
     
  • Quit smoking
     
  • Avoid putting pressure on the abdomen, eg when stooping and bending
     
  • Prop up their head and shoulders when in bed, to prevent acid reflux
     
  • Try some relaxation exercises to avoid stress.
Treatment

While the points mentioned above will help your patients prevent indigestion and heartburn from occurring, the immediate course of action is to treat the symptoms.

Customers seeking short-term relief have the option of using either an antacid, an alginate or a combination product. The question for pharmacy staff is: what product should they recommend?

Antacids

Antacids work by neutralising the stomach acid (see diagram 1, above), which in turn prevents the damage and erosion of the oesophagus and stomach, which cause discomfort.

The ability to neutralise depends on the metal salt in the formulation – some have a quick onset but are short-acting, whereas others have a slower onset but a longer duration.

There is sometimes a risk of diarrhoea or constipation with certain metal salts used in antacids.

You should recommend that customers take antacids after eating, because gastric emptying is delayed in the presence of food – therefore allowing the antacid to have a longer effect.

Because [antacids] act like a buffer and neutralise the acid, drugs that are sensitive to pH may be affected

– so there may be some interaction.

Alginates

If heartburn is the main issue, the first-line treatment should be an alginate.

They work by forming a sponge-like matrix – sometimes known as a ‘raft’ – when they come into contact with acid. This ‘raft’ then floats on top of stomach content (see diagram 2, above) and prevents acid from flowing up the throat and producing the symptoms of heartburn.

Combination products

Combination products are also available, which combine the neutralising power of an antacid with the raft-forming alginate (see diagrams 3 and 4, above).

These provide superior symptom control compared to using either an antacid or an alginate alone, as they can treat the – typically overlapping – range of symptoms present.

Combination products can be taken after meals and before bed as a preventative measure, but may be used as required depending on the patient’s need.

Also, the combination of metal salts used in these products often prevents the negative side effects seen in antacids containing only one metal salt.

Acid-suppressing medication

There are two groups of medicine that can be used to suppress acid production: H2 antagonists and proton pump inhibitors (PPIs). Both are effective at reducing acid secretion in the stomach, although they take longer to take effect compared to either antacids or alginates.

What formulation?

Every patient will have a preference for which product suits them best. For example, they may want a liquid formulation because they have used it before and know it works. Others may prefer a sachet or tablet form, as they can carry this easily.

Whatever option you recommend, the information in this article will ensure you are ready to provide the highest quality care and advice to each of your patients.

When should you refer a patient?

You should routinely refer individuals who:

  • After four weeks, still experiences the symptoms of indigestion unless they take an antacid
     
  • Has taken an indigestion or heartburn remedy for two weeks, with no relief of symptoms
     
  • Is taking a prescribed medicine that you suspect is causing the symptoms.

You should urgently refer to a GP if your patient experiences:

  • New symptoms and is over 55
     
  • Unexplained weight loss
     
  • Persistent unexplained vomiting
     
  • Black or tarry stools
     
  • Progressive difficulties swallowing
     
  • A gnawing, sharp or stabbing pain.

Refer your patient to the hospital if you suspect their heartburn symptoms have a sinister origin. It is important pharmacy staff ask about the location of the pain – if it radiates to other areas of the body, it is indicative of a non-gastrointestinal origin. The pain might be cardiovascular, especially if it is felt down the inside of the left arm.

A lot of these patient groups overlap – they are smokers or overweight, and they are at high risk of cardiovascular
disease, but they may also present with heartburn. If they are experiencing severe episodes of chest pain – which could
be reflux – it is important to exclude a cardiac cause first.

Dr Ayesha Akbar

3 Comments
Question: 
What challenges do you face when advising patients with these conditions?

Valentine Trodd, Community pharmacist

"first-line treatment should be an alginate"

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Gerry Diamond, Primary care pharmacist

I find that in discussion with patients looking at life style, eating habits, trigger factors and taking a good history are important. Usually do an inspection of abdomen, abdominal masses, check oral cavity for cyanosis, tongue for signs such of crohns, or anemia any liver flap sx from hands, examine sigmata, pulse, check eyes for for sx such as jaundice. Ubilical area for portal hypertension.

Palpate the abdomen,  check quadrants for tenderness,  soft palpation and then deep palpation. Locate position of liver, palpate for splenomelagy, palpate  kidneys, indirect and direct herniation of inguinal and femoral areas.

Oscultate abdomen, aorta, and umbilical area for bowel sounds and  bruits. Oscultate renal angle for bruits. Examine legs for oedema.

request LFT, TFT, HbA1cc , lipis,renal function and HP test. await results.

Give PPI in interim and review in two weeks. simple lolx

Valentine Trodd, Community pharmacist

You forgot the most important bit... sign them up for an MUR.

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