Heartburn, Dyspepsia & Intestinal Gas PDF

Heartburn, Dyspepsia & Intestinal Gas Prepared by: Dr. Sarah M. Khayyat Outlines Background Clinical presentation Non-pharmacologic & pharmacologic Management Red-flag symptoms/exclusion for self- assessment Points for practice Heartburn Background Heartburn is a form of indigestion...

Heartburn, Dyspepsia & Intestinal Gas Prepared by: Dr. Sarah M. Khayyat Outlines Background Clinical presentation Non-pharmacologic & pharmacologic Management Red-flag symptoms/exclusion for self- assessment Points for practice Heartburn Background Heartburn is a form of indigestion (or dyspepsia), which is also more formally known as gastro-esophageal reflux disease (GERD). Symptoms are caused when there is reflux of gastric contents, particularly acid, into the esophagus, which irritates the sensitive mucosal surface (esophagitis). Patients will often describe a burning discomfort/pain felt in the stomach, passing upwards behind the breast-bone (retrosternal). The symptoms occur more commonly in older people, but can occur in young adults and pregnant women. Heartburn is the main symptom of GERD, but similar symptoms also may occur in patients with peptic ulcer disease, delayed gastric emptying, gallbladder disease, or other GI disorders.  Signs and symptoms of heartburn Typical esophageal symptoms include heartburn (burning feeling in the chest) and regurgitation (acid and undigested food flowing back into the throat or mouth) The burning discomfort is experienced in the upper part of the stomach in the midline (epigastrium), and the burning feeling tends to move upwards behind the breastbone (retrosternal). The pain may be felt only in the lower retrosternal area or occasionally right up to the throat, sometimes associated with an acid taste in the mouth and trouble swallowing. Heartburn is noted most frequently within 1 hour after eating, especially after a large meal, or with ingestion of triggering food.  Signs and symptoms of heartburn Heartburn is often brought on by bending or lying down → which cause increase pressure on the lower esophageal sphincter → leading to leakage of the acid up to the esophagus. Atypical (extraesophageal) symptoms caused by the abnormal reflux include: o Stomach upset and pain o Flatulence o Chest pain o Unexplained cough and/or wheezing o Hoarseness or sore throat o Nausea and vomiting.  Signs and symptoms of heartburn In general, symptoms may be considered mild if they bother the patient a little but do not interfere with normal activities. Symptoms that are somewhat bothersome or annoying, or that interfere with normal activities, may be considered moderate. Heartburn symptoms that occur two or more times per week are suggestive of GERD. Signs and symptoms of heartburn Precipitating factors for heartburn Information about precipitating or aggravating factors should be obtained. These may exert their effect by directly irritating the esophagus or by increasing the likelihood of reflux occurring. These include: Overweight, obese people, pregnant woman Eating a large meal or late meal before going to bed Eating trigger foods, such as coffee, chocolate, peppermint, tomatoes, garlic, onion, citrus fruits, and fried, fatty or spicy foods Smoking and alcohol consumption Stress and anxiety. Precipitating factors for heartburn Some medicines are commonly associated with heartburn and people may notice symptoms shortly after starting them, these include: Calcium channel blockers, such as amlodipine Antidepressants, particularly those with more pronounced antimuscarinic (anticholinergic) effects, such as amitriptyline Theophylline Nitrates Iron supplements The phosphodiesterase inhibitors, such as sildenafil and tadalafil Precipitating factors for heartburn Some medicines may aggravate esophagitis when occur such as: NSAIDs Aspirin Oral corticosteroids Bisphosphonates (e.g., alendronate and risedronate), which are taken for treating osteoporosis; therefore, it is important that people drink water and stay upright after taking them. Exclusions for self-management Children or people who aged 55 and over with ‘alarm features’ Severe pain → a referral is needed when the pain come on suddenly and severely, and even radiate to the back and arms → differentiation of symptoms is difficult as the pain can mimic a heart attack Regurgitation, difficulty in swallowing (or dysphagia) → the difficulty may be either discomfort when food or drink is swallowed or a sensation of food or liquids sticking in the gullet → both require referral as it may be due to obstruction of the esophagus by a tumor or result from severe esophagitis with inflammation and narrowing Long duration and/or worsening over time Failure to respond to antacids Symptoms related to prescribed medication Exclusions for self-management National Institute for Health and Care Excellence (NICE) alarm features: Advice about when to consult the GP: Adults presenting with dyspepsia or reflux symptoms should be advised to see their GP if their symptoms have persisted for several weeks, get worse over time or do not improve with medication. They should be advised to see their GP urgently if they have dysphagia or if they are aged 55 and over with additional symptoms that may be a cause for concern, including weight loss, haematemesis, nausea or vomiting, or upper abdominal pain. Questions for self-management Indigestion or Dyspepsia Background Indigestion (dyspepsia) is upper abdominal discomfort or pain. It is commonly presented in community pharmacies and is often self- diagnosed by patients, who may use the term indigestion to include anything from pain in the chest and upper abdomen to lower abdominal symptoms. Many patients use the terms indigestion and heartburn interchangeably and there may be an overlap in symptoms. There is usually no need for medical advice for indigestion as it is often mild and infrequent. Dyspepsia can be organic (i.e., has an identifiable cause) or functional (i.e., has no identifiable organic, systemic, or metabolic disease).  Signs and symptoms of dyspepsia The symptoms of typical indigestion include: Poorly localized upper abdominal (the area between the umbilicus and the ribcage) Discomfort described as a burning sensation (heartburn or regurgitation), heaviness or ache, which may be brought on by particular foods, excess food, alcohol consumption or medication (e.g. NSAIDs or aspirin). Often related to eating, it may be accompanied by symptoms such as nausea, fullness in the upper abdomen or belching. Precipitating factors for dyspepsia Diet: fatty foods or excessive consumption can cause indigestion and aggravate ulcers and may precipitate biliary colic if there is gall bladder abnormality. Smoking and alcohol consumption, particularly in large amounts. Medication causing indigestion such as: ○ NSAIDs and aspirin due to risk of ulceration in stomach and duodenal. ○ The antiplatelet drug clopidogrel increases risk of GI bleeding. Precipitating factors for dyspepsia Other medication induced dyspepsia Exclusions for self-management Children especially if abdominal pain is of unknown cause First-time indigestion in older people (NICE recommendation for age threshold is 55 years of age or over) Unexplained and unintentional weight loss Difficulty in swallowing (dysphagia) Persistent or recurrent nausea or vomiting Blood in vomit or stool Patient concerned by a lump or mass in the stomach Persistent abdominal pain (> 5 days), particularly if severe or unrelated to meals Treatment failure or suspected adverse drug reaction (e.g., with NSAID) Iron deficiency anemia (however, this diagnosis will require a blood test) Questions for self-management Management of heartburn & dyspepsia Both conditions have similar non-pharmacological and pharmacological management Treatment goals: 1. Provide complete relief of symptoms 2. Reduce recurrence of symptoms 3. Prevent and manage unwanted effects of medications. Non-pharmacological management Lose weight if they are overweight or obese Avoid any trigger foods Eat smaller meals and their evening meal 3–4 h before going to bed, if possible. Stop smoking, reduce alcohol consumption Sleep with the head of the bed raised (e.g., by placing wood or bricks under the bedhead to raise it by 10–20 cm, if practical) Sleep on the left side Avoid tight clothing that squeeze the stomach area, especially waistbands and belts Assess for stress and anxiety, which may worsen symptoms, and encourage relaxation strategies, if needed. Pharmacological management Treatment timescale for heartburn: Where no ‘red flag’ symptoms are present, and if symptoms have not responded to treatment after 2 weeks, the patient should see a doctor. Treatment timescale for dyspepsia: If symptoms have not improved within 5 days, the patient should see the doctor. Pharmacists will use professional judgement to decide whether to offer antacids, alginates or a proton pump inhibitor (PPI) as first-line treatment. The selection of the medication should be based on frequency, duration, and severity of symptoms; the cost of the medication; potential drug–drug interactions and adverse effects; and the patient’s preference. Pharmacological management 1. Antacid Antacids has a rapid action and have a greater neutralizing capacity. They used for mild symptoms but they work only for short duration. Liquids are more effective antacids than solids. The liquid allows a large surface area to be in contact with the gastric contents. Some patients find tablets more convenient, and these should be well chewed before swallowing. It might be appropriate for the patient to have both; the liquid could be taken before and after working hours, while the tablets could be taken during the day for convenience. Pharmacological management 1. Antacid Antacids are best taken about 1h after a meal because the rate of gastric emptying has then slowed, and the antacid will therefore remain in the stomach for longer. If taken at this time, antacids may act for up to 3h compared with only 30 min to 1h if taken before meals. Repeated doses may be needed for full effect. Antacid preparations that are high in sodium should be avoided by those who are pregnant and anyone on a sodium-restricted diet (e.g., those with heart failure or kidney or liver problems). Antacids can be more effective in combination with an alginate. Pharmacological management 1. Antacid Sodium bicarbonate: It is water soluble, acts quickly, is an effective neutralizer of acid and has a short duration of action. It should not be used alone for the relief of heartburn or indigestion; it is present as an ingredient in many indigestion remedies where it gives a fast- acting effect in combination with longer-acting agents. If a preparation low in sodium is required, the pharmacist can recommend one containing potassium bicarbonate instead. Alginate products with low sodium content are useful for the treatment of heartburn in patients on a restricted sodium diet. Pharmacological management 1. Antacid Sodium bicarbonate: It should be avoided in patients who are taking lithium as it increases excretion of lithium, leading to reduced plasma levels. Long-term use of sodium bicarbonate may lead to systemic alkalosis and renal damage. However, in short-term use, mixed with other ingredients, it can be useful. Its use is more appropriate in acute rather than chronic dyspepsia. Patients who take calcium supplements should avoid using sodium bicarbonate as an antacid. Sodium and potassium salts are the most highly soluble, which makes them have a quicker onset but are shorter acting. Pharmacological management 1. Antacid Aluminum and magnesium salts Examples: aluminum hydroxide and magnesium trisilicate Aluminum-based antacids are effective, but they tend to cause constipation, thus, best to be avoided in anyone who is constipated and in elderly patients who have a tendency to constipation. Magnesium salts are more potent than aluminum salts. However, they tend to cause osmotic diarrhea as a result of the formation of insoluble magnesium salts and are useful in patients who are constipated or prone to consitpation → Combination products containing aluminum and magnesium salts may cause less bowel disturbance. Pharmacological management 1. Antacid Aluminum and magnesium salts Example of products that contain different antacid active ingredients is Maalox and Mylanta, which contain aluminum hydroxide, magnesium hydroxide, and simethicone. They can be taken between or after meals, and/or at bedtime. Should be used with caution in patient with kidney diseases and those on magnesium restricted diet. Magnesium and aluminum salts are less soluble, so have a slower onset, but greater duration of action. Pharmacological management 1. Antacid Calcium carbonate, e.g., TUMS (have the advantage of being quick acting yet have a prolonged action) It can cause acid rebound and, if taken over long periods at high doses, hypercalcemia and so should not be recommended for long-term use. If calcium carbonate and sodium bicarbonate are taken in large quantities with a high intake of milk, they can result in the milk-alkali syndrome. This involves hypercalcemia, metabolic alkalosis and renal insufficiency; its symptoms are nausea, vomiting, anorexia, headache and mental confusion. Calcium carbonate may cause constipation, belching & flatulence due to carbon dioxide production. Pharmacological management Simethicone It is sometimes added to antacid formulations for its defoaming properties. It reduces surface tension and allows easier elimination of ‘trapped’ gas from the gut by facilitating passage of flatus or eructation (belching). Evidence of benefit is uncertain. Pharmacological management 2. Alginates (e.g., the Gaviscon range) Alginates interacts with stomach acids and form a gel-like raft that sits on the surface of the stomach contents and prevents reflux. They start acting within a few seconds after taking them. Examples: sodium alginate, sodium bicarbonate, calcium carbonate, and potassium bicarbonate. Some alginate-based products contain sodium bicarbonate, which, in addition to its antacid action, causes the release of carbon dioxide in the stomach, enabling the raft to float on top of the stomach contents. Different OTC forms are available such as supplements, powders, and liquids. Pharmacological management 2. Alginates (e.g., the Gaviscon range) Some products include different ingredient such as GAVISCON, it contains sodium alginate, calcium carbonate, and sodium bicarbonate. GAVISCON advance contains higher concentration of sodium alginate, providing an enhanced protective barrier. It is available as oral suspension, and chewable tablet. Oral suspension should be shaked well before use. Best to be administered after meal with water or other liquid and at bedtime (4 times daily). Alginate preparations are reported not to have any side effects or interactions with other medicines. Pharmacological management 3. Proton pump inhibitors (PPIs) Used in adults aged 18 and over with frequent and more severe symptoms, and they are the most effective medicines for relief of heartburn. Some are sold without prescription such as esomeprazole, omeprazole, pantoprazole, lansoprazole. PPIs should not be taken during pregnancy or while breastfeeding. Diarrhea is a common side effect, and constipation is sometimes seen. Treatment with PPIs may cause a false-negative result in the ‘breath test’ for Helicobacter pylori. Pharmacological management 3. Proton pump inhibitors (PPIs) PPIs may take time to start being fully effective, e.g., omeprazole takes 1-4 days to work. During this period, a patient with ongoing symptoms may need to take a concomitant antacid. PPIs tablets or capsules should be swallowed whole with plenty of liquid 30 to 60 minutes prior to a meal. PPI tablets and capsules should not be chewed or crushed, because the enteric coating will be compromised, thereby decreasing the effectiveness of the drug. Do not take more than 1 tablet a day. Complete resolution of symptoms should be noted within 4 days of initiating treatment. Pharmacological management 4. Histamine type 2 receptor antagonists (H2RAs) Example OTC drugs: cimetidine, ranitidine, famotidine, and nizatidine. H2RA last longer and is preferable to an antacid when patients with mild to moderate episodic heartburn require more prolonged relief of symptoms. However, H2RAs do not relieve heartburn or dyspepsia as rapidly as antacids do, but they may be used with an antacid if both quick relief and longer duration of action are desired. H2RAs used to prevent heartburn and acid indigestion if they are given 30 minutes to 1 hour before situations in which heartburn is anticipated. Pharmacological management 4. Histamine type 2 receptor antagonists (H2RAs) A reduced daily H2RA dose is recommended in patients with impaired renal function (creatinine clearance < 50 mL/minutes). Self-treatment dosing should be limited to no more than 2 times a day. If routine self-treatment with an H2RA is needed for more than 2 weeks, medical referral is recommended. The most common adverse effects reported with all four H2RAs are headache, diarrhea, constipation, dizziness, and drowsiness. Thrombocytopenia is a rare but serious adverse effect associated with H2RAs, but this condition is reversible upon the discontinuation of the drug. Pharmacological management 4. Histamine type 2 receptor antagonists (H2RAs) Lower dose OTC H2RA products (e.g., famotidine 10 mg up to twice daily) should be recommended for patients with mild, infrequent heartburn. Higher dose nonprescription products (e.g., famotidine 20 mg up to twice daily) should be reserved for moderate symptoms. Pharmacological management Medication comparisions Additional points for practice Antacids or OTC histamine type 2 (H2) receptor antagonists should be recommended for patients with mild to moderate, infrequent heartburn or dyspepsia. Antacids should preferably not be taken at the same time as other drugs since they may impair absorption and may also damage enteric tablet coatings designed to prevent breakdown in the stomach → also adverse effects may occur if the drug is released earlier than intended in the stomach. Sodium bicarbonate may increase the excretion of lithium and lower the plasma level. A reduction in lithium’s therapeutic effect may occur, so sodium bicarbonate is best avoided. Additional points for practice Taking the doses of antacids and other drugs at least 1h apart should minimize interactions. Antacid dosing may be repeated in 1–2 hours, if needed, but should not exceed the maximum daily dosage for a particular product. The changes in pH that occur after antacid administration can result in a decrease in iron absorption if iron is taken at the same time → Taking iron and antacids at different times should prevent this problem. PPIs work best when taken daily, unlike antacids and H2RAs, which are taken as needed. Patients taking a PPI should be advised not to take H2 antagonists at the same time. Special Populations Geriatric population The 2019 updated American Geriatrics Society (AGS) Beers Criteria for Potentially Inappropriate Medication (PIM) Use in Older Adults recommend avoiding H2RAs in geriatric patients with or at high risk for delirium, owing to their potential for inducing or worsening delirium. A short course of a PPI, consistent with OTC labeling is acceptable. H2RAs are OTC labeled for patients 12 years of age and older, and PPIs are indicated for patients 18 years of age or older. Omeprazole, esomeprazole, and lansoprazole may be used in patients with renal impairment. Special Populations Renal impairment Omeprazole, esomeprazole, and lansoprazole may be used in patients with renal impairment. Aluminum- or magnesium-containing antacids should be used sparingly, if at all, in patients with decreased renal function; if an H2RA is appropriate, the lower dose should be selected. Cimetidine should be avoided because of associated increased risks for adverse effects and drug–drug interactions. In general, patients with kidney dysfunction should consult their primary care provider before self-treatment with antacids. Special Populations Pregnancy and Breastfeeding women Alginates works locally in the stomach (not systematically absorbed); therefore, it is safe for pregnant and breastfeeding women. H2RAs are considered to be compatible with pregnancy. Data are limited but indicate no increased risk of congenital malformations. Famotidine is less concentrated in breast milk and may be preferable to cimetidine or ranitidine. Limited data indicate that low levels of omeprazole, esomeprazole, and lansoprazole appear in breast milk. Summary of medications used in heartburn & dyspepsia Resources Blenkinsopp A, Duerden M, & Blenkinsopp J. (2022). Symptoms in the pharmacy: a guide to the management of common illnesses. John Wiley & Sons. Rutter, P. (2020). Community pharmacy: symptoms, diagnosis and treatment. Elsevier Health Sciences. Krinsky, D. L., Ferreri, S. P., Hemstreet, B. A., Hume, A. L., Rollins, C. J., Tietze, K. J. (2021). Handbook of non-prescription drugs: an interactive approach to self- care. APhA. 20th Edition. WWW.Lexidurg.com WWW.Medscape.com