Pharmacists have a key role to play in the treatment of GORD, but they must adopt a holistic approach to patients and to the condition
Gastro-oesophageal reflux disease (GORD) is a very common condition, and one of the most common presentations to most community pharmacies.
But is the pharmacy sector managing the condition well and providing optimal health outcomes to patients?
A very common condition
Reflux of gastric contents into the oesophagus is a normal physiological event, occurring usually during the postprandial period.
Gastro-oesophageal reflux disease (GORD) occurs when reflux exposes the patient to the risk of physical complications, or symptoms lead to a significant impairment of wellbeing or quality of life, the Gastroenterological Society of Australia says in its most recent clinical update on the condition.
“Clinically significant impairment of wellbeing (quality of life) usually occurs when symptoms are present on two or more days a week,” defines the Gastro society (GESA).
Reflux disease is common, being experience by between 15 and 20% of adults experience heartburn at least once a week.
According to the Australian Institute of Health and Welfare (AIHW), it “causes a well-documented high disease burden on the Australian community, and large health expenditures for both health services and pharmaceuticals”.
AIHW data from 2008 estimated the prevalence of GP-diagnosed gastro-oesophageal reflux disease in Australia to be 10.4% of patients attending GPs and 9.2% of the Australian population.
“This equates to approximately 2 million Australians with GORD. The prevalence of GORD in the Australian community is similar to that of osteoarthritis, asthma or depression.”
“The hospital admission rate for GORD is also significant with 60,064 admissions to Australian hospitals with GORD with or without oesophagitis in 1998–00 and 61,049 in 2006–07,” the AIHW report added.
The main risk factors
Among the key risk factors for GORD are:
- Obesity (BMI >30kg/m2);
- alcohol consumption (> 7 standard drinks a week); and
- a first-degree relative with heartburn increase the risk of having reflux symptoms.
In addition, patients with connective tissue diseases such as scleroderma, chronic respiratory diseases such as asthma and cystic fibrosis, institutionalised and intellectually handicapped people, and patients nursed in a supine position for prolonged periods are at increased risk of reflux disease and its complications.
Symptoms directly related to reflux episodes include:
- Heartburn – according to GESA, the “hallmark symptom of reflux disease”. It is characterised by a feeling of burning rising up from the stomach or lower chest towards the neck. It is typically provoked by meals, especially those containing fatty or highly spiced food or by bending, straining or lying down. It is usually eased or relieved by antacids.
- Regurgitation – the other characteristic symptom of reflux disease. Regurgitated material is usually re-swallowed but is sometimes so voluminous that it may be mistaken for ‘vomiting’. Some patients may experience regurgitation as their predominant symptom, particulary if gastric acid secretion is suppressed.
- Waterbrash – oesophageal acidification may cause such sudden and brisk stimulation of salivation that the patient’s mouth fills with saliva. This may be associated with nausea.
- Atypical symptoms including: angina-like chest pain, throat/voice changes, cough, asthma, excessive belching, dyspepsia and nausea. These symptoms are nonspecific and do not in themselves imply the presence of reflux.
Symptoms caused by complications of reflux disease include:
- Dysphagia – Dysphagia may be due either to inflammation, defective oesophageal peristalsis or heightened oesophageal sensitivity. Dysphagia that is associated with symptoms of bolus impaction is suggestive of a stricture or ring.
- Odynophagia (painful swallowing) – this is usually associated with severe oesophagitis but may also be due to excessive sensitivity of the oesophageal mucosa.
- Bleeding from oesophagitis – Haematemesis may be a presenting symptom but is rarely severe. Occasionally, iron deficiency may result from severe oesophagitis (however other causes must be excluded).
The gold standard
In patients with typical symptoms, treatment can be based on symptoms alone with a trial of PPI therapy, say Keung and Hebbard in Australian Prescriber.
Treatment would be reduced after a response is established, they advise. Further investigation is required if there are ‘red flags’, a lack of response to the trial or complications of GORD.
PPIs now represent 91% of prescribed medications for GORD, said Dr Ben Basger, clinical pharmacist at the University of Sydney.
Writing in AJP in 2016, Dr Basger said “the Royal Australian College of General Practitioners has recommended that doctors don’t use proton pump inhibitors long term in patients with uncomplicated GORD without regular attempts at reducing or ceasing the dose.
“Acid suppressant therapy is effective in controlling the symptoms of GORD, but does not cure the disease,” Dr Basger said. Relapse is common on withdrawal of therapy, which may explain why many patients continue on long-term therapy.
Variation in severity means that no single management plan suits everyone. It should be noted that GORD causes a significant reduction in health-related quality of life and that generally PPIs have a relatively good safety record, compared with other commonly prescribed medications”.
We should reassure patients that GORD can be controlled with lifestyle changes and short courses of PPIs, advises consultant pharmacist Debbie Rigby.
“PPIs are more effective than H2-receptor antagonists such as ranitidine. It’s important to counsel patients to take PPIs 30 to 60 minutes before meals for optimal effect. They have the greatest efficacy in the post-prandial period due to their mechanism of action,” she said.
The safety profile of PPIs is well established after more 20 years of use, Ms Rigby said, adding that the are highly effective but with some safety concerns, especially with higher doses in long-term use.
The PPI position
As is well known, there have been claims of adverse effects from long term use of PPIs. They have been associated with a slight increase in the rates of bacterial gastroenteritis, community acquired pneumonia, osteoporosis and hip fracture, as well as bacterial overgrowth of the small intestine and outbreaks of Clostridium difficile colitis in elderly patients in hospitals.
The absolute risk of these complications is very low, the Gastroenterological Society says.
“These adverse effects are uncommon, but nevertheless PPIs should only be prescribed in the lowest effective dose for the shortest period of time,” said Debbie Rigby.
She does believe that too many people are maintained on PPIs, placing them at risk for long-term adverse effects.
“Pharmacists can start the conversation with patients about tapering the dose, with the view to ceasing or changing to prn use,” she says.
“It’s important that PPIs aren’t abruptly stopped, and rebound hypersecretion may occur, leading to people inappropriately restarting their PPI. PPI doses should be tapered over a couple of weeks, with advice to use antacids or alginates if rebound symptoms occur. Deprescribing guidelines for PPIs are available…”
Talking it out
Pharmacists also need to broaden their role in this area to include engaging with patients and discussing a range of treatment options – both pharmacological and non-pharmacological, said ms Rigby.
“We need to have a conversation with the patient about GORD triggers and non-pharmacological strategies to reduce symptoms,” she said.
“Weight loss has the strongest evidence for efficacy. Diets high in sugar, fat and salt, and smoking should be avoided. We need to ask the patient to describe their symptoms in detail – what makes it worse and what makes it better”.
Gastroenterologists Charlotte Keung and Geoffrey Hebbard, writing in Australian Prescriber agree that, of the non-pharmacological approaches to GORD management, weight loss is the most important.
“It has been shown to have a dose-dependent association with reduction of symptoms,” they said. “A reduction in the body mass index of 3.5 kg/m2 can result in nearly a 40% reduction in the risk of having frequent symptoms”.
Other lifestyle modifications they recommend include elevation of the head of the bed and avoidance of meals 2–3 hours before bedtime if there are nocturnal symptoms.
“While routine global elimination of specific food groups triggering reflux is not recommended, patients should avoid foods that specifically trigger their symptoms. Cessation of tobacco and alcohol are recommended but, while this may help some patients, it has not been shown to improve symptoms overall.
A red flag
Red flag symptoms should prompt an immediate referral to their GP. Patients with persistent symptoms after 14 days use of OTC PPIs should be referred to their GP. Typical symptoms of GORD usually respond to 4 to 8 weeks therapy, and then the dose should be reduced to when required.
Further investigation is required if there are ‘red flags’, a lack of response to the trial or complications of GORD, said Keung and Hebbard.
Box: Red flags in gastro-oesophageal reflux
- Recurrent vomiting
- Dysphagia or odynophagia
- Weight loss
- Evidence of gastrointestinal blood loss e.g. haematemesis, iron deficiency or anaemia
- Duration of symptoms >5 years or <6 months
- Epigastric mass
- Age >50 years
Source: NPS Australian Prescriber
Debbie Rigby says a qualified pharmacist could conduct a MedsCheck to determine if there are any medication-related causes for ongoing issues.
“A medication history is important to identify any drugs that may be causing or exacerbating GORD signs and symptoms, as well as potential drug interactions. Medicines like calcium channel blockers, anticholinergics, nitrates and bisphosphonates are common culprits,” she said.
“Calcium carbonate supplements require an acid environment for optimal absorption. So, pharmacists should suggest switching to calcium citrate supplements in people taking long-term PPIs and calcium supplements for osteoporosis treatment and prevention”.
“With the upscheduling of codeine combination products to prescription only, we may see more requests for NSAIDs,” said Ms Rigby.
“Whilst OTC NSAIDs should only be used for a few days at a time, pharmacists have an opportunity to recommend concomitant OTC PPIs in at-risk people for gastroprotection”.
Symptoms of reflux disease
Source: Australian Prescriber
AIHW General practice in Australia, health priorities and policies 1998 to 2008: Gastro-oesophageal reflux disease, 2010
GESA Gastroenterological Society of Australia, clinical update, Reflux Disease, 2011
The management of gastro-oesophageal reflux disease, Charlotte Keung and Geoffrey Hebbard, Aust Prescr 2016;39:36-9
GORD: The bad and the ugly, AJP, May 2017
Non-prescription treatment of NSAID induced GORD by Australian pharmacies: a national simulated patient study., McFarlane, B et al Int J Clin Pharm. 2015 Oct;37(5):851-6