The guts of the problem

Due to the high prevalence of reflux symptoms in the general community and an array of over-the-counter options, many people turn to their local pharmacist first for treatment advice

Despite wide variance in estimates of the prevalence of gastro-oesophageal reflux disease (GORD), it’s believed that approximately 10–15% of Australians experience reflux symptoms.

“GORD or gastro-oesophageal reflux disease is best defined as symptoms or complications resulting from the reflux of gastric contents into the oesophagus and beyond. ‘Beyond’ includes the mouth and lungs.

“Heartburn, or a burning sensation in the chest, is just one symptom that results from GORD. Many people can have GORD without heartburn. For example, they may have only regurgitation as a symptom. Or they can experience symptoms such as cough, belching and water brash (sour acid taste in the mouth),” explains Dr Vincent Ho, gastroenterologist and lecturer at Western Sydney University.

“A presumptive diagnosis of GORD can be made based on the typical symptoms of heartburn or regurgitation.

“Heartburn is classically described as a burning, retrosternal, rising sensation associated with meals. This can be quite difficult to define for many people and it would be useful for pharmacists to clarify the nature of the symptoms when the term heartburn is used.

“For example if a person states that their heartburn is a central heavy chest pain, which radiates to the left arm and is worse with exertion that is much more likely to be cardiac angina than GORD.

“Occasionally, there may be alternative causes of heartburn—other than GORD. These include oesophageal cancers, peptic ulcer, large hiatus hernias and rare medical conditions such as eosinophilic oesophagitis and achalasia. Some people even had a condition called functional heartburn, where objective tests have been carried out to rule out excess acid exposure in the oesophagus, but they nonetheless experience episodic symptoms.

“Regurgitation, on the other hand, is described as the effortless appearance of gastric contents in the throat or mouth without associated nausea or retching. People often use the lay term ‘reflux’ to describe regurgitation. A history of vomiting or retching should prompt the pharmacist to think that something than GORD may be present.

“The key thing for pharmacists to note is that with typical symptoms (heartburn and regurgitation), GORD is the most likely explanation,“ Dr Ho advises.

Risk factors and red flags

The risk factors for GORD include hiatal hernia, obesity and smoking. Obesity is linked to a notable increase in the risk for GORD. What’s more, the growing rate of obesity is likely related to the increasing prevalence of GORD in Western countries.

Alexandra Argyrou et al  (2018) explain the association between obesity and increased risk of GORD comes from the fact that obesity can lead to increased abdominal pressure, delayed gastric emptying and higher frequency of transient LES relaxations in the lower esophageal sphincter.

Hiatal hernia can loosen the lower esophageal sphincter, reduce esophageal clearance and increase reflux. Studies suggest the size of the hernia is directly linked to the severity of reflux symptoms.

As for smoking, the risk of GORD increases with the duration of smoking and amount of tobacco smoked. It is the nicotine in the cigarettes that causes the lower oesophageal sphincter to relax, which increases the risk of reflux. Smoking is also associated with other lifestyle habits that are thought to aggravate GORD symptoms, such as drinking alcohol and caffeine.

Certainly, for pharmacists dealing with requests for the treatment of GORD symptoms, alarm symptoms would play a vital role.

Dr Ho says, “If there are any alarm or ‘red flag’ symptoms that the patient describes, this should be a time to pause and ask the patient to see their GP for a timely review before dispensing an over-the-counter medication.”

Red flag symptoms include:

  • a history of recurrent vomiting or retching;
  • swallowing difficulties;
  • weight loss;
  • a history of vomiting blood or anaemia;
  • duration of symptoms more than 5 years or less than 6 months; and
  • symptoms occurring in a person older than 50 years

Treating GORD symptoms in pharmacy

“In many cases, acid reflux is not a serious condition and symptoms can be managed with over-the-counter or prescription medicines,” says general practitioner, Dr Jill Thistlewaite.

“Several over-the-counter medicines are effective in relieving symptoms of acid reflux. These medicines are available in a liquid or tablet form. Antacids relieve symptoms by neutralising the stomach acid and include brands such as Rennie, Eno and Gaviscon.

“Alginates form a gel that attaches to the stomach contents and creates a barrier that prevents the reflux from entering the oesophagus.

“H2-receptor-antagonists, on the other hand, work by reducing the amount of acid produced by the stomach and include brands such as Zantac. Although both H2-receptor-antagonists and antacids provide rapid relief of symptoms in patients with acid reflux, antacids are ineffective in managing symptoms in the long term and should be reserved for the relief of mild or occasional symptoms only.”

Dr Ho adds, “I would recommend an alginate as a good initial treatment for patients with mild GORD symptoms. In practice, most commercial alginates will have a small amount of antacid combined with them.

“However, a systematic review has found alginates to be superior to both placebo and antacids for controlling GORD symptoms in adults. The data has also shown that alginates taken in a liquid form (such as Gaviscon 10mls four time a day) is an effective short-term option for patients with mild GORD.”

Countering the negativity

Despite the negative reports in recent years, proton pump inhibitors (PPIs) remain the mainstay treatment for suspected GORD. They can be recommended as an appropriate initial treatment for frequent symptoms in uncomplicated cases, where no red flags are present.

Dr Ho says, “There has indeed been a lot of reports in the media about the safety of PPIs. There is no causal link between PPI use and an increased risk of death. While there are some concerns as to the long-term safety of PPIs, the evidence generally shows a weak effect.

“The majority of available data on safety are derived from observational studies that look at past data and don’t take fully into account other medical conditions the study subjects might have had.

“That being said, PPIs in general do appear to be overprescribed in Australia for excessively long periods of time and particularly among older people.

“It’s important to ensure that PPIs are used for the appropriate medical indications and for the shortest duration where possible. Their continued use should be reviewed regularly.

“Also, there are some people who believe PPIs don’t help their heartburn, but this can be because they’re not taking the medicine correctly.

“PPI use for the treatment of heartburn is not going to be effective for patients if they don’t comply with taking a recommended course. Studies have found that PPI compliance is generally quite low in patients with GORD, with adherence to daily PPI use at only 55% at one month after receiving the prescription from their doctor.

“There are two key areas in which pharmacists can really help ensure that PPIs are taken optimally. Firstly, they can provide education around the proper timing of administration. Secondly, they can encourage patient compliance.

“Pharmacists have an opportune time at the point of dispensing to be able to give advice about both of these important points.”

Key points to counsel on include:

  • PPIs are indicated for short-term use (OTC PPIS should be taken for a maximum of 14 days);
  • PPIs are administered once daily;
  • they should be taken at the same time each day;
  • they should be taken 60 minutes before the largest meal of the day for optimal effect (allows the short half-life drug maximum time to inhibit the active proton pump);
  • unlike antacids, PPIs are not to be taken symptomatically;
  • antacids and alginate can be used to treat breakthrough symptoms;
  • lifestyle modifications, particularly weight loss and avoiding known triggers, can help reduce symptoms of GORD;
  • long-term use of PPIs can contribute to polypharmacy, adverse reactions and drug interactions; and
  • once symptoms are controlled, PPI therapy should be ceased or reduced to the lowest dose possible.

“The ‘step-down’ approach is recommended for most people with mild to moderate GORD. I normally recommend an eight-week course of a PPI and then ‘step down’ to a minimum dose for symptom control, which is usually intermittent, patient‑driven therapy (i.e. patients only take it on days when symptoms occur).

“Pharmacists can really assist this approach at the point of dispensing by clarifying that the PPI prescribed provided by the doctor is for a limited period of time.

“However, in some instances the PPI use will be regular rather than intermittent and potentially for a longer period of time than a couple of months. An example might be in patients with Barrett’s oesophagus or severe oesophagitis.

“In most circumstances though, the PPI course will be for a limited period of time and the pharmacist can reinforce the importance of ‘stepping down’ to an intermittent, patient-driven therapy. The same advice should apply to over-the-counter PPIs,” says Dr Ho.

Adjunct lifestyle advice

For some people with GORD symptoms, diet and lifestyle modifications may be sufficient to reduce their symptoms.

“Studies have found that weight loss and tobacco smoking cessation should be recommended to GORD patients who are obese and smoke, respectively. Avoiding late evening meals and elevating the head of the bed is effective for nocturnal GORD. Increased dietary fibre has also been shown to be helpful in reducing the frequency of heartburn symptoms,” advises Dr Ho.

Additional lifestyle tips that may help reduce GORD symptoms include:

  • avoiding foods that aggravate reflux symptoms (e.g. citrus, chocolate, tomato based products, spicy foods, high-fat content foods) without overly restricting diet;
  • limiting intake of alcohol and other beverages with a low pH (e.g. carbonated drinks);
  • eating smaller meals more frequently, rather than large meals less often;
  • avoiding large meals, especially close to bedtime;
  • avoiding lying down or vigorously exercising shortly after meals; and
  • exercising regularly.

Of the non-pharmacological approaches to the management of GORD, weight loss has been identified as having the strongest evidence for efficacy.

A reduction in the body mass index of 3.5kg/m2 can reduce the risk of frequent symptoms by nearly 40%. However, individuals need to be encouraged to maintain their weight loss. Even short-term weight gain is associated with a three to four-fold higher risk of GORD symptoms.

While pharmacists are masters of medicine, lifestyle and preventative advice should always be an adjunct offering in a bid to improve health outcomes.

More information
Argyrou A, et al. Risk factors for gastroesophageal reflux disease and analysis of genetic contributors. World J Clin Cases. 2018;6(8):176-82.

MacFarlane B. Management of gastroesophageal reflux disease in adults: a pharmacist’s perspective. Integr Pharm Res Pract. 2018 Jun 5; 7: 41-52.

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