Treatment of Heartburn at Pharmacy

Symptoms

Symptoms of heartburn are caused when there is reflux of gastric

contents, particularly acid, into the oesophagus, which irritate the

sensitive mucosal surface (oesophagitis). Patients will often describe

the symptoms of heartburn; typically a burning discomfort/pain felt in

the stomach passing upwards behind the breastbone (retrosternally).

By careful questioning, the pharmacist can distinguish conditions that

are potentially more serious.

Significance of questions and answers

Age

The symptoms of reflux and oesophagitis occur more commonly in

patients aged over 55. Heartburn is not a condition normally experienced

in childhood, although symptoms can occur in young adults and

particularly in pregnant women. Children with symptoms of heartburn

should therefore be referred to their doctor.

Severe pain

Sometimes the pain can come on suddenly and severely and even

radiate to the back and arms. In this situation differentiation of

symptoms is difficult as the pain can mimic a heart attack and urgent

medical referral is essential. Sometimes patients who have been admitted

to hospital apparently suffering a heart attack are found to have

oesophagitis instead.

Difficulty in swallowing (dysphagia)

Difficulty in swallowing must always be regarded as a serious symptom.
The difficulty may either be discomfort as food or drink is
swallowed or a sensation of food or liquids sticking in the gullet.
Both require referral (see ‘When to refer’ box below). It is possible
that discomfort may be secondary to oesophagitis from acid reflux
(gastro-oesophageal reflux disease (GORD) ), especially when it
occurs whilst swallowing hot drinks or irritant fluids (e.g. alcohol or
fruit juice). A history of a sensation that food sticks as it is swallowed
or that it does not seem to pass directly into the stomach (dysphagia) is
an indication for immediate referral. It may be due to obstruction of
the oesophagus, e.g. by a tumour.

Pregnancy

It has been estimated that as many as half of all pregnant women

suffer from heartburn. Pregnant women aged over 30 are more likely

to suffer from the problem. The symptoms are caused by an increase in

intra-abdominal pressure and incompetence of the lower oesophageal

sphincter. It is thought that hormonal influences, particularly progesterone,

are important in the lowering of sphincter pressure.

Medication history

some drugs can cause

the symptoms of heartburn, e.g. anticholinergic agents such as hyoscine

and drugs with anticholinergic actions such as tricyclic antidepressants

and phenothiazines. Calcium channel blockers, nitrates

(especially nifedipine), theophylline and aminophylline can also aggravate

heartburn, as can caffeine in compound analgesics or when

taken as a stimulant.

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. 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

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.

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).

Life style modifications

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 (see ‘Prevention of heart
disease’). The knowledge that the discomfort of heartburn will be
reduced can be a motivating factor in giving up cigarettes.