Anyone who’s experienced reflux knows only too well how uncomfortable that burning feeling can be. But when it occurs frequently it can lead to inflammation and potential ulceration of the oesophagus. Hence, the importance of the pharmacists’ role in the treatment and ongoing management of reflux, writes Leanne Philpott.
- GORD is quite a common condition in Australia and generally, pharmacies will be the first point of call for customers seeking relief from symptoms, particularly in the early stages.
- GORD symptoms can negatively impact on a person’s physical and occupational function, emotional state and social interactions.
- The role of the pharmacist is to always be involved in any query relating to gastrointestinal symptom request. They have the appropriate skills to identify any need for referral that pharmacy assistants do not have, to cross check a patient’s self-diagnosis and identify the need for referral.
- If GORD is suspected, a trial of proton pump inhibitors (PPIs) for two weeks may be considered the mainstay of treatment—to suppress gastric acid production, unless referral is indicated.
Gastro-oesophageal reflux disease (GORD) is the inflammation of the oesophagus caused by the involuntary reflux of gastric acid from the stomach. While occasional reflux is a normal bodily function, the Gastroenterological Society of Australia (GESA) says, “GORD occurs when reflux exposes the patient to the risk of physical complications or symptoms leading to a significant impairment of wellbeing or quality of life.”
Indeed, GORD symptoms can negatively impact on a person’s physical and occupational function, emotional state and social interactions. Around 11% of the Australian population has GORD, with 15–20% of adults experiencing heartburn, a classic GORD symptom, at least once a week.
GORD symptoms occur when the stomach acid and food contents are refluxed into the oesophagus and the excessive erosive effects result in injury and inflammation. The cause of the reflux action is due primarily to defective lower oesophageal sphincter (LOS) function.
According to the Australian Institute of Health and Welfare (AIHW), even though GORD has not been declared a National Health Priority Area, it has been shown to have a high disease burden on the Australian community. It says the prevalence of GORD is increasing in Australia and worldwide, with the rise in overweight and obesity a contributing factor.
Some of the risk factors and comorbidities associated with GORD include:
- weight gain or obesity;
- a family history of GORD or heartburn; and
“Pharmacists can offer counselling on reducing the risk factors for GORD. As with many of the conditions we see, lifestyle can be a major contributor to GORD. Pharmacists are well placed to provide advice on quit smoking therapies and to counsel on other ways to assist smoking cessation,” says Terry White Chemists clinical services pharmacist, Krystel Tresillian.
“For obesity we can recommend a weight management program, provide support and information, along with appropriate products, to assist customers to reach a healthy weight.
“For stress we can counsel customers on non-pharmacological therapies, which may reduce stress, and refer them to their GP if necessary,” says Tresillian.
Rachel Dienaar, practice support pharmacist for the Pharmaceutical Society of Australia (PSA), says lifestyle and preventative advice should always be offered, but especially when people have associated risk factors.
“Being actively involved in the primary healthcare consultation is the most important aspect [of pharmacy services], otherwise a pharmacist’s knowledge and skills to assist the consumer are wasted and will not result in improved health outcomes,” she says.
“The role of the pharmacist is to firstly always be involved in any query relating to gastrointestinal symptom request. They have the appropriate skills to identify any need for referral that pharmacy assistants do not have, to cross check a patient’s self-diagnosis and identify the need for referral. A pharmacist actively involved in primary healthcare will be positioned in the pharmacy to allow such access by consumers, a concept strongly supported by PSA’s ‘Health Destination Pharmacy’ model,” says Dienaar.
Dienaar says a key point to consider is the regularity of symptoms; when reflux occurs frequently and becomes problematic it is known as GORD, and the need for referral should always be assessed.
“The pharmacist’s role is to engage in a ‘patient-centred’ consultation to identify GORD symptoms, either during a primary healthcare consultation or during a script consultation, or when providing either a MedsCheck service or home medicines review,” says Dienaar.
Key symptoms of GORD include:
- regurgitation; and
Despite heartburn being a hallmark symptom of GORD, not all people with heartburn meet the definition of GORD. Discussing the patient’s symptoms is paramount to ensuring the correct diagnosis has been made.
Katie Ellard, clinical adjunct associate professor in medicine at the University of Notre Dame Medical School and chair of the Digestive Health Foundation, says, “Heartburn and indigestion mean different things to different people. The other trick is some people who complain of chest pain will have heart disease and can’t distinguish it from heartburn. GP referral is necessary for these patients. But if the pain is a burning pain, radiating up into the throat and is influenced by eating and improved by antacids you are on the right track with heartburn.”
“Pharmacists can play a key role in the treatment and management of patients in a number of ways, one of which is ensuring customers are referred to a GP for accurate diagnosis of the underlying cause of their symptoms which may be GORD, non-ulcer dyspepsia, ulcer, H.Pylori or potentially something more sinister. If there are any alarm signs present, the customer should be referred to a GP,” says Tresillian.
Red flag symptoms include:
- dysphagia (difficulty swallowing); • odynophagia (painful swallowing);
- nocturnal choking;
- suspected gastrointestinal bleeding;
- vomiting with blood or persistant vomiting; and
- involuntary weight loss.
Dienaar adds that patient referral is also necessary when atypical symptoms are present, when symptoms occur daily or recur within five days of stopping treatment, there is a family history of gastrointestinal cancer, or the person is taking long-term NSAID therapy.
Atypical symptoms include:
- cardiac type chest pain;
- crushing chest pain;
- pain radiating to the back, neck, jaw or arms, or discomfort exacerbated by exercise; and
- non-specific gastrointestinal symptoms—abdominal pain or discomfort, nausea, belching, bloating, hoarseness, sore throat or cough.
“GORD can be an adverse effect resulting from medication and pharmacists are able to draw on their expert understanding of medication and interplays to identify and assist with the management of this,” Tresillian says.
“When counselling a customer with symptoms suggesting GORD, pharmacists should ask if they are taking calcium-channel blockers, dopaminergic agents, anticholinergics, nitrates, theophylline, bisphosphonates, oral corticosteroids, tetracyclines, iron, potassium chloride or prescription NSAIDs, and if so, discuss any concerns with the prescriber or, alternatively, refer the customer to their prescriber. There may be alternatives available that will not cause undesired symptoms, and other potential causes or adverse effects, such as ulcer, need to be ruled out or investigated,” says Tresillian.
“As with many conditions, the pharmacist should be watchful of symptoms that persist despite therapy, or that appear to be worsening. A good test of severity is to ask how frequently a customer experiences symptoms and whether they are severe enough to interfere with normal activities. These are a red flag requiring further investigation,” adds Tresillian.
Tresillian says, “GORD is quite a common condition in Australia and generally, pharmacies will be the first point of call for customers seeking relief from symptoms, particularly in the early stages. Many customers will refer to their condition as ‘heartburn’ or ‘reflux’ and may be familiar with the treatments available over the counter for such conditions.”
“The main recommendation is that patients seek pharmacist advice and pharmacists actively aim for consistent and sustainable involvement in patient product selection for its appropriateness,” says Dienaar.
“If GORD is suspected, a trial of proton pump inhibitors (PPIs) for two weeks may be considered the mainstay of treatment—to suppress gastric acid production, unless referral is indicated. Existing medical conditions and current medication interactions should, of course, be considered. Treatment of 2–4 weeks with a PPI can be diagnostic of GORD, however referral after two weeks should be recommended. The long-term use of PPIs, including safety issues, should be managed by the patient’s GP,” advises Dienaar.
“Antacids neutralise gastric acid by increasing gastric pH. They have a rapid onset and short duration of action and are suitable for mild intermittent or occasional breakthrough symptoms,” she adds.
“There are many effective treatments so decisions and recommendations are best made in tandem with the customer and prescriber, if at all possible,” says Tresillian.
Katie Ellard tells the AJP, “The main change in the area [of reflux] is the increasing recognition that an attempt should be made to find the lowest dose of medication at which symptoms are reasonably controlled. The reason for this is the recognition that the PPI drugs are associated with increased risk of fractured femur and clostridium difficult infection. A paper has also recently been published suggesting that PPIs reduce effective absorption of vitamin B12.”
Given this, Ellard says she prefers a ‘step-up’ approach. “I favour a step-up approach, starting with avoiding foods that cause trouble, then moving onto antacids and then OTC H2 antagonists—with the PPIs as the step up from that.”
Ellard points out that pharmacist just need to remain aware of the risks with long-term use of PPIs. She says, “You can’t predict potential complications with any accuracy but you can keep a look out and inform patients of these possible problems with PPIs and long-term use.”
Common side effects of PPIs include:
- abdominal pain;
- constipation; and
It’s important to identify those people who would rather take a pill than make changes to their lifestyle; pharmacists can play a crucial role in counselling on the fact that medication should never be a replacement for lifestyle modification and intervention.
Dienaar says, “Lifestyle and preventative advice should always be offered, especially to those in the target groups (smokers and those who are overweight or obese).”
“Healthy eating and appropriate weight are measures we should all emphasise. Quite a lot of people will lose their reflux symptoms if they reduce weight back to a healthy BMI,” says Ellard.
Dienaar lists the following lifestyle tips to help reduce or prevent GORD:
- avoid foods that aggravate reflux symptoms (for example, citrus, chocolate, tomato-based products, spicy foods, high-fat content foods):
- limit intake of alcohol and other beverages with a low pH (for example, carbonated drinks);
- eat smaller meals more frequently, rather than large meals less often;
- eat slowly and chew food well;
- avoid large meals, especially close to bedtime;
- avoid lying down shortly after meals;
- avoid wearing tight-fitting garments after meals;
- raise the bedhead or use a wedge pillow if nocturnal or laryngeal symptoms are troublesome;
- maintain a healthy weight and lose weight if overweight;
- quit smoking;
- maintain a correct posture and bend from the knees (not the spine); and
- exercise regularly.
“At every dispensing of medication pharmacists should be involved in discussion around the efficacy of medications, adverse effects and supporting lifestyle information to prevent symptoms and assist in the control of GORD,” says Dienaar.
Pharmacy support services
MedsCheck is a professional, remunerated service that pharmacists can offer to support the prevention and treatment of GORD. Through this service, pharmacists can investigate the needs of the consumer and, with particular focus on medication taking behaviour, assist them to achieve the optimal use of medicines, with the aim of improving health outcomes.
WEIGHT LOSS AND HEALTHY EATING PROGRAMS
In-pharmacy health promotions – raise awareness of how consumers can help prevent and treat GORD through lifestyle change.
Community education and engagement activities—provide improved health outcomes to the community and serve as a promotional activity for the services the pharmacy provides in the area of GORD and primary healthcare advice.
Effective collaboration and communication with GPs – an essential consideration for ensuring uptake of referral and review of treatment recommendations.
CASE STUDY – Why Good counselling is crucial
Elise Apolloni, a pharmacist at Capital Chemist Wanniassa, ACT says, “Good communication and counselling is absolutely crucial; having conversations with customers about their symptoms is paramount and underpins everything we do in pharmacy. We can’t guess or assume just because a customer has had reflux once before, it doesn’t mean it’s reflux the next time they come in.
“A good example of this is when we had a middle‑aged man visit the pharmacy complaining that his gastric reflux medication was not working and he was still getting symptoms.
“By taking the time to talk to the man and further enquire about his symptoms I learnt that he was still suffering from a central rising pain consistent with reflux, but also aches in the arms, back and neck—in addition to general fatigue and the onset of radiating chest pain.
“Without raising too much alarm I talked to the patient about the possibility of a heart attack and advised that he should investigate, this promptly and referred him to the hospital.
“A week or so later the man returned to the pharmacy to thank me, because he had in fact experienced a heart attack.
“This man was not a regular customer but now he is a very valuable and loyal customer of the. pharmacy. He comes in every month and says thanks for saving his life!”
- The Gastroenterological Society of Australia (GESA) offers downloadable health information, including a consumer fact sheet on Heartburn and a clinical update on Reflex Disease. Visit www.gesa.org.au.
- Pharmacists should refer to PSA’s ‘Guidance for the provision of proton pump inhibitors as Pharmacist-Only medicines’ at www.psa.org.au.