Heartburn & Dyspepsia Overview

Heartburn & Dyspepsia Overview

• Overall prevalence of heartburn in the US is 42% over a one-year period, predominantly in white individuals.
• Weekly heartburn symptoms are reported by 20% of respondents.
• Women experience heartburn slightly more than men, and the overall incidence is increasing globally, particularly in Western countries.
• The annual cost associated with heartburn in the US is $18.1 billion, encompassing both direct and indirect costs.
• Prescription medications represent a significant expense (54%) in managing heartburn.

Symptoms

• "Heartburn" is the most common symptom, characterized by a burning sensation in the stomach and lower chest, which may sometimes radiate to the neck or back.
• Heartburn may also be described as indigestion, acid regurgitation, sour stomach, or bitter belching.
• Dyspepsia is another term used for "bad digestion," encompassing symptoms originating from the gastroduodenal region.
• Dyspepsia includes post-prandial fullness, early satiety, epigastric pain, and epigastric burning.
• Less specific symptoms of dyspepsia include bloating, nausea, vomiting, and belching.

Definitions

• GERD (gastroesophageal reflux disorder) is characterized by symptoms, esophageal damage, or both, resulting from abnormal reflux of gastric contents. Some individuals can experience GERD without esophageal damage (NERD).
• Frequent heartburn occurs two or more days per week.
• Persistent heartburn constitutes three or more months of symptoms, a typical symptom of GERD.

Contributing Factors

• Dietary: Alcohol, carbonated beverages, chocolate, citrus fruits, fatty foods, garlic, onions, spearmint, peppermint, salty foods, spices, tomatoes and tomato juice.
• Lifestyle: Exercise, emotions, obesity, smoking, stress, supine posture, tight-fitting clothing.
• Medications: Adrenergic antagonists, anticholinergic agents, aspirin, NSAIDs, barbiturates, benzodiazepines, beta-2 agonists, bisphosphonates, calcium channel blockers, chemotherapy medications, clindamycin, dopamine, estrogen, iron, narcotic analgesics, nitrates, potassium, progesterone, prostaglandins, quinidine, tetracycline, theophylline, and zidovudine.
• Diseases: Motility disorders (gastroparesis), peptic ulcer disease (PUD), scleroderma, Zollinger-Ellison syndrome, insulin resistance, Sjogren's syndrome.
• Other: Genetics, pregnancy.

Treatment Goals

• Achieve complete relief of symptoms.
• Reduce recurrence of symptoms.
• Prevent and manage adverse effects of medications.

Treatment Approaches

• Treatment plans vary based on the frequency and severity of heartburn symptoms:
  • Episodic/infrequent heartburn
  • Moderate/infrequent heartburn
  • Frequent heartburn (≥2 days/week)

Exclusions for Self-Treatment

• Frequent heartburn lasting more than three months
• Heartburn persisting after two weeks of treatment with over-the-counter H2RAs or PPIs
• Heartburn continuing despite use of prescription strength H2RAs or PPIs
• Nocturnal heartburn
• Severe heartburn symptoms
• Difficulty or pain swallowing solid foods
• Chronic hoarseness, wheezing, coughing, or choking
• Note or complaint of GI bleeding, unexplained weight loss, continuous nausea/vomiting/diarrhea, chest pain associated with sweating, pain radiating to arm/neck/jaw, shortness of breath
• Pregnancy or breastfeeding (for antacids)
• Children (vary by age for different medications)

Non-Pharmacologic Measures

• May benefit some but not all patients.
• Patients should track dietary, lifestyle, and medication triggers to identify patterns. Avoid foods that cause symptoms.
• Reduce meal sizes.
• Avoid lying down after eating.
• Eat no later than three hours before bedtime.
• Elevate head of bed 6-8 inches.
• Avoid smoking, alcohol, and caffeine.
• Consider weight loss if overweight.
• Consider switching medications if necessary.

Antacids

• Basic Compounds: Antacids neutralize stomach acid by a chemical reaction, increasing stomach pH and inhibiting pepsinogen conversion into pepsin.
• Potency: Different antacids have varying potencies in neutralizing acid, and those based on similar compounds are not interchangeable; potency should be determined per product.
• Onset/Duration: Antacid effects generally last 20-60 minutes, sometimes longer if consumed with food.
• Indications: Mild, infrequent heartburn, sour stomach, and acid indigestion.

Comparisons of Various Antacid Compounds:

• Sodium Bicarbonate (Baking Soda):*
• Potent, highly soluble in water.
• Systemically absorbed into the bloodstream.
• Can potentially cause alkalosis when used alone.
• Chronic use may lead to milk-alkali syndrome if coupled with calcium.
• Adverse events include belching, flatulence, fluid retention, weight gain, edema, and risk of chronic use for those with renal failure or cirrhosis.
• Calcium Carbonate (e.g., Tums):*
• Dissolves more slowly than sodium bicarbonate.
• Creates potent and prolonged neutralization
• Chronic ingestion can cause hypercalcemia.
• Adverse events include belching, flatulence, and constipation.
• Aluminum Hydroxide (e.g., Amphojel):*
• Dissolves slowly.
• Relatively low acid neutralizing capacity (ANC).
• Adverse events include constipation and hypophosphatemia, with possible aluminum toxicity with long-term use, especially in those with renal failure.
• Magnesium Hydroxide (e.g., MOM):*
• Relatively potent acid-neutralizing capacity.
• Can cause diarrhea due to osmotic imbalances.
• Can lead to hypermagnesemia in those with renal issues.
• Combination Products:* Combination products (e.g., Maalox) can combine aluminum and magnesium hydroxides for efficacy and to mitigate some side effects.

H2 Receptor Antagonists

• Mechanism: Competitively and reversibly bind to H2 receptors on parietal cells to decrease gastric acid secretion.
• Tolerance: Tolerance may develop with daily use; intermittent dosing is potentially preferred.
• Short-term use: Effective for short-term symptoms of heartburn, acid indigestion, and sour stomach, primarily for relief from fasting and nocturnal symptoms.

Proton Pump Inhibitors (PPIs)

• Mechanism: Irreversibly inhibit H+-K+-ATPase (proton pumps) on the surface of parietal cells.
• Indications: For frequent heartburn (two or more days/week)
• Onset Duration and Timing: Onset happens in ~30-60 min and persists for four to ten hours, potentially prolonged with concurrent use of antacids.

PPI Products

• Omeprazole, Esomeprazole, Lansoprazole, and others are available in various formulations and strengths for both OTC and prescription use.

Adverse Effects of All Types of Acid Reflux Medications

• Mild side effects are common, such as headache, dizziness, nausea, diarrhea, and occasionally constipation.
• Potential for serious adverse effects is low.
• Long-term use of some drugs can result in deficiencies (e.g., B12, magnesium, iron), osteoporosis risks, increased susceptibility to infections, and other issues.
• Particular concerns arise for individuals with kidney problems, high-risk groups, and/or those taking multiple medications at once.

Drug Interactions

• Numerous drug interactions exist with each type of reflux medication.
• Avoid concomitant use of drugs that may inhibit the absorption of one another or may have conflicting effects.

Bismuth Subsalicylate

• Mechanism of action: Topical effect on stomach mucosa (treats local symptoms, not the acid levels in the stomach directly).
• Indications: Heartburn, upset stomach, indigestion, nausea, and diarrhea.
• Dosage: 2-4 times more daily, depending on the individual need.

This quiz explores the prevalence, symptoms, and economic impact of heartburn and dyspepsia. Participants will learn about the demographics affected, common symptoms, and the costs associated with managing these conditions. Test your knowledge on this important health topic!