A guide to symptomatic reflux management
Materials sponsored and developed by Reckitt Benckiser Healthcare UK/G-NHS/0813/0044 August 2013 Prescribing information is available on page 8
Symptomatic reflux management Upper gastrointestinal (GI) symptoms are extremely common. With more than 50% of sufferers taking medication1,2 and up to 45% supplementing prescription treatments with over-the-counter medicines,3 the pharmacy is an important destination for people experiencing troublesome symptoms. Research shows that customers with upper GI symptoms value the advice and counselling given by pharmacists, and it can have a measurable impact on health-related quality of life.4 Gastro-oesophageal reflux is a common cause of upper GI symptoms.5 Most reflux patients experience multiple, overlapping symptoms, such as heartburn, regurgitation and dyspepsia,6 which can make it difficult to fully control symptoms. In recent years, new evidence has advanced our understanding of the factors and mechanisms that are important in symptomatic reflux. Because of this, now is a good time for pharmacists to re-acquaint themselves with this condition. This booklet reviews the latest research and recommendations in reflux, including the need for an individualised approach to achieve optimal control of symptoms.
Strategies beyond acid neutralisation Despite the fact that reflux is not a disorder of excess acid, acid suppression or neutralisation is often the main focus of treatment.7 While this is effective in relieving some symptoms, other reflux symptoms are less acid-related and might not be adequately controlled using acid-suppressant therapies alone.7 For example, acid suppression with proton pump inhibitors (PPIs) is considerably less beneficial in the treatment of regurgitation than for heartburn.8,9 It is now known that weakly acidic gastric contents and other factors such as bile and pepsin also cause reflux symptoms.5,7 Acid suppression does not prevent reflux related to these non-acid factors and a significant proportion of PPI-treated patients (up to 45%) will experience residual symptoms, largely regurgitation.10,11
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Reflux suppression Reflux is a mechanical process and the identification and avoidance of factors that trigger this process may benefit symptomatic individuals.12 The lower oesophageal sphincter (LOS), found where the oesophagus meets the stomach, is a muscular valve that prevents gastric contents flowing back up into the oesophagus.13 The LOS opens briefly when the stomach is bloated to allow gas to escape (belching). This process is called transient LOS relaxation and usually occurs after eating.13 It is this transient relaxation of the LOS that sometimes allows reflux of the stomach contents into the oesophagus.13 In addition to bloating, other factors can cause transient LOS relaxation (see Table 1). Certain medications can also cause dyspepsia, including bisphosphonates, calcium antagonists, corticosteroids, nitrates, non-steroidal anti-inflammatory drugs (NSAIDs) and theophylline.14
Food and drinks
Raw onion Chocolate Caffeine Peppermint Citrus juice Tomato products Fatty food Spicy food Carbonated drinks Coffee and tea Alcohol
Medications
Beta-blockers Sedatives/tranquilisers Tricyclic antidepressants Theophylline Calcium channel blockers Anticholinergics
Hormones
Progesterone in pregnancy
Drugs
Nicotine Table 1: Factors reported to reduce lower oesophageal sphincter pressure15
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Reflux symptom management First contact
Alarm symptoms requiring referral to a doctor14
As the pharmacist is often the first healthcare professional consulted by people with reflux symptoms,16 it is important to question patients carefully to determine whether they are suffering from any of the alarm symptoms in Table 2.14 A customer with one or more of these symptoms should be referred to their doctor.
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Difficulty swallowing Unexpected weight loss Abdominal mass/swelling Persistent vomiting Gastrointestinal bleeding Iron-deficiency anaemia Age older than 55 years with recent-onset, persistent or unexplained dyspepsia
Table 2: Alarm symptoms requiring referral to a doctor14
Lifestyle modification Table 3 lists some dietary and lifestyle advice that might help limit the mechanical process of reflux. It is important to tailor recommendations to the individual’s symptom pattern and lifestyle, rather than offering broad, general advice.12
Advice for changes in lifestyle and diet12,14,17
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Implement a healthy eating approach Lose weight (for those who are overweight) Avoid known dyspepsia triggers, including: •
Alcohol
•
Certain foods (e.g. chocolate, citrus juice, tomato-based products, peppermint, coffee and onion)
•
Fatty food
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S top smoking Avoid large meals (for those with postprandial symptoms) Decrease intake of fatty and spicy food (for those with postprandial symptoms) Elevate the head of the bed (for those with night-time symptoms) Avoid lying down for 3 hours after eating
Table 3: Advice for changes in lifestyle and diet12,14,17
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Reflux medication For patients whose symptoms cannot be satisfactorily controlled with lifestyle factors alone, the pharmacological options are outlined in Table 4. Speed of relief is an important factor for patients choosing reflux medication.16 Alginate formulations and antacids offer the most rapid symptom relief, making them the best options for on-demand treatment.16 Alginates have been shown to have a soothing effect within 3 minutes,18 whereas antacids have been shown to take around 10 minutes to take effect.19,20 Owing to their mode of action, PPIs do not provide immediate symptom relief and are normally reserved for patients with more troublesome symptoms.16,21
Therapy
Uses
Antacids
»»Mild reflux
Alginates
Mechanism
»»Reduce
acidity in the stomach and oesophagus23
21
22
»»Mild/moderate reflux »»Form a buoyant raft providing a physical barrier to reflux »»Co-therapy with PPIs for residual 21
24
symptoms21
»»Aid PPI weaning
21
H2-receptor antagonists
»»Mild/moderate reflux »»PPI intolerance »»Co-therapy for night-time 21
»»Reduce acid secretion
22
21
symptoms21 PPIs
»»Moderate/severe reflux
21
»»Reduce acid secretion
22
Table 4: Pharmacological options for reflux
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Treatment modes of action Imaging experiments have shown how traditional antacids rapidly sink to the bottom of the stomach whereas raft-forming alginate treatments remain at the top of the stomach, close to the gastro-oesophageal junction (Figure 1).25
Air
Air
Meal
Alginate GOJ
GOJ
Antacid
Meal
Figure 1: MRI imaging of a raft-forming alginate (Gaviscon Advance; sodium alginate and potassium carbonate) and a non-raft-forming antacid (Alucol) taken after a meal26 Adapted from Fox M et al. Poster presentation, DDW 2011
The rapidly sinking antacid will be emptied from the stomach, resulting in a relatively short duration of action, while the alginate raft will keep working in the stomach for up to 4 hours after it is taken.27,28 As a result, raft-forming alginates can provide longerlasting relief than traditional antacids,27 which need to be taken repeatedly after meals to maintain relief.27 An alginate-antacid combination (Gaviscon Double Action; sodium alginate, sodium bicarbonate and calcium carbonate 325 mg) has been shown to form a raft at the top of the stomach, creating a physical barrier that blocks acid reflux.29 The reflux-suppressing mode of action of alginate-antacids may make them useful for patients with symptoms that are less related to acid, such as regurgitation. Ask your customers to describe their symptoms: if they experience a bitter or acidic taste in the back of the throat or mouth then an alginate formulation may be a suitable option.
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Adjuvants to prescription treatments Research shows that many patients taking PPIs have to supplement their prescription therapy with over-the-counter treatments to achieve satisfactory control of their symptoms.3 Persistent symptoms can be partly due to the fact that acid suppression does not stop the mechanical process of reflux.30 The unique reflux-suppressing mode of action of alginates makes them useful for co-therapy. Supplementing PPIs with alginates is proven to double the number patients who experience complete symptom relief compared with PPI therapy alone.31
Summary
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The majority of reflux symptoms occur after eating.
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Management strategies need to consider the mechanical process of reflux and other gastric factors, such as pepsin and bile acids.
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Optimal management requires individualised care according to lifestyle and symptom patterns.
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Alginate-antacids may benefit customers with symptoms after meals, with a hiatus hernia or whose symptoms are not controlled with acid-reducing therapy alone.
Reducing acidity in the stomach does not always fully resolve reflux symptoms.
Gaviscon Advance Peppermint Flavour Oral Suspension, Gaviscon Advance Aniseed Suspension, Gaviscon Advance Mint Chewable Tablets. Active substances: Gaviscon Advance Peppermint Flavour, Gaviscon Advance Aniseed Suspension: Each 5 ml dose contains sodium alginate 500.0mg and potassium hydrogen carbonate 100.0mg Gaviscon Advance Mint Chewable Tablets: Sodium alginate 500 mg and Potassium bicarbonate 100 mg per tablet. Indications: Treatment of symptoms resulting from the reflux of acid, bile and pepsin into the oesophagus such as acid regurgitation, heartburn, indigestion (occurring due to the reflux of stomach contents), for instance, after gastric surgery, as a result of hiatus hernia, during pregnancy, accompanying reflux oesophagitis, including symptoms of laryngopharyngeal reflux such as hoarseness and other voice disorders, sore throats and cough. Can also be used to treat the symptoms of gastro-oesophageal reflux during concomitant treatment with or following withdrawal of acid suppressing therapy. Dosage Instructions: Gaviscon Advance Peppermint Flavour Oral Suspension, Gaviscon Advance Aniseed Suspension: Adults and children 12 years and over: 5-10 ml after meals and at bedtime (one to two 5 ml measuring spoons). Gaviscon Advance Mint Chewable Tablets: For oral administration after being thoroughly chewed. Adults and children 12 years and over: One to two tablets after meals and at bedtime. Children under 12 years: Should be given only on medical advice. Elderly: No dose modification is required for this age group. Contraindications: Hypersensitivity to any of the ingredients, including the esters of hydroxybenzoates (parabens). Precautions and Warnings: Care needs to be taken in treating patients with hypercalcaemia, nephrocalcinosis and recurrent calcium containing renal calculi. There is a possibility of reduced efficacy in patients with very low levels of gastric acid. Treatment of children younger than 12 years of age is not generally recommended, except on medical advice. If symptoms do not improve after seven days, the clinical situation should be reviewed. Gaviscon Advance Peppermint Flavour Oral Suspension, Gaviscon Advance Aniseed Suspension: Each 10 ml dose has a sodium content of 106 mg (4.6mmol) and a potassium content of 78 mg (2.0 mmol). This should be taken into account when a highly restricted salt diet is recommended, e.g. in some cases of congestive cardiac failure and renal impairment or when taking drugs which can increase plasma potassium levels. Each 10 ml contains 200 mg (2.0 mmol) of calcium carbonate. This medicinal product contains Methyl hydroxybenzoate and Propyl hydroxybenzoate, which may cause allergic reactions (possibly delayed). Gaviscon Advance Mint Chewable Tablets: Each two-tablet dose has a sodium content of 103mg (4.5mmol) and a potassium content of 78mg (2.0mmol). This should be taken into account when a highly restricted salt diet is recommended, e.g. in some cases of congestive cardiac failure and renal impairment or when taking drugs which can increase plasma potassium levels. Each two-tablet dose contains 200 mg (2.0 mmol) of calcium carbonate. Gaviscon Advance Tablets may cause central nervous system depression in the presence of renal insufficiency and should not be used in patients with renal failure. Due to its aspartame content this product should not be given to patients with phenylketonuria. Side-Effects: Very rarely (
