Pharmacy customers can be quite vague when talking about GI problems so it is important to ask them to describe their symptoms to help clarify the complaint
After reading this feature you should be able to:
- Identify patients with dyspepsia or GORD
- Discuss the symptoms of GORD
- Explain simple lifestyle measures that can help ease symptoms
Patients often struggle to find the right words to describe upper abdominal pain or discomfort, bloating, heartburn and acid reflux. But whatever terminology they use, about 40 per cent of the UK adult population have symptoms each year and around a quarter will consult their GP.
According to NICE guidance on gastro-oesophageal reflux disease and dyspepsia in adults (last updated in October 2019), dyspepsia has no universally accepted definition. The British Society of Gastroenterology says that use of the term 'dyspepsia' indicates there is an underlying disease of the upper digestive tract, rather than a specific diagnosis. Underlying causes of dyspepsia include gastro-oesophageal reflux disease (GORD), peptic ulcer disease, Barrett’s oesophagus and upper gastrointestinal cancers.
Around 70 to 80 per cent of people with dyspepsia symptoms have functional dyspepsia, where their endoscopy results are normal. This may mean there is a problem with how their digestive system works, rather than a problem that can be seen and diagnosed (such as an ulcer). Uninvestigated dyspepsia describes symptoms in people who haven’t had an endoscopy.
Intermittent dyspepsia symptoms (once a week, a few times a month, or once a month or less) are generally caused by lifestyle factors and don’t usually have any long-lasting effects. However, frequent symptoms (occurring twice a week for four weeks) often have an underlying cause and can affect daily activities, work productivity and sleep quality.
Gastro-oesophageal reflux disease
GORD is caused when the stomach contents (especially acid, bile and pepsin) reflux up the oesophagus towards the mouth. This is thought to be triggered by a combination of factors, such as relaxation of the lower oesophageal sphincter muscle, increased intra-gastric pressure (for example, from straining and coughing), delayed gastric emptying and impaired oesophageal clearance of acid.
Dr Philip Woodland, consultant gastro-enterologist at London Digestive Centre, part of The Princess Grace Hospital, says that heartburn is a classic symptom of gastro-oesophageal reflux disease. "It can last anywhere from a few minutes to several hours," he says. "It can come on at any time, but most commonly will occur after someone’s eaten, or when they lay down too soon after eating."
Other GORD symptoms include chest pain (behind the breastbone), an unpleasant taste in the mouth and swallowing problems. GORD may also affect the throat and respiratory tract, causing hoarseness, cough, asthma and dental erosions in some people.
The risk of GORD increases with age, and the disease is slightly more common in women than in men. It may occur in pregnancy.
Risk factors also include stress and anxiety, smoking and alcohol, obesity, trigger foods (e.g. coffee, chocolate and fatty foods) and family history. "In many but not all cases, GORD occurs due to the presence of a hiatus hernia," says Dr Woodland. "This is when a portion of the stomach slips upwards through the diaphragm, resulting in a weakened anti-reflux barrier."
According to NICE guidance, community pharmacists should offer initial and ongoing help for people with dyspepsia and GORD symptoms. This includes advice about lifestyle changes, using over-the-counter medicines, help with prescribed medicines and when to consult a GP. Pharmacists should also provide customers with access to educational materials to support the care they receive.
Simple lifestyle measures for dyspepsia symptoms include:
- Weight loss (if someone is overweight or obese)
- Eating smaller, lower fat meals
- Eating the evening meal three to four hours before going to bed
- Raising the head of the bed with bricks at the base
- Stopping smoking
- Reducing alcohol consumption to below the recommended guidelines
- Relaxation and psychological therapies (e.g. cognitive behavioural therapy and psychotherapy), as stress, anxiety and depression can make dyspepsia symptoms worse.
"Pharmacists should recommend that people don’t eat a meal late and go straight to bed," says Dr Marion Sloan, a GP in Sheffield and member of the Primary Care Society for Gastroenterology (PCSG). "The worst thing someone can do after a meal is to have coffee, a mint and a cigarette: all are smooth muscle dilators of the lower oesophageal sphincter, promoting reflux."
Sufferers should be advised to avoid certain foods and drinks but may need to keep a food and symptom diary as triggers vary from person to person. "Avoid spicy foods, fizzy drinks and caffeine-containing foods and drinks, such as coffee, tea and chocolate," says Julie Thompson, information manager at Guts UK charity. "Other foods might also be problematic and people should request a referral to a dietitian if these need to be explored," she adds.
Some medicines may cause or worsen dyspepsia symptoms – these include anticholinergics, beta-blockers, corticosteroids, NSAIDs and tricyclic antidepressants. Pharmacists should offer medication reviews and refer customers back to their GP when necessary.
Before recommending OTC dyspepsia treatments, it is important to ask patients about the frequency of their symptoms, and whether they have already tried OTC antacids and/or alginates. These medicines are best taken when symptoms occur or are expected, usually between meals and at bedtime. Liquid products are more effective than tablets. Some medicines contain both an alginate and an antacid.
Self-treatment with an antacid and/or alginate may be useful for the short-term control of GORD symptoms, but long-term, continuous use isn’t recommended. Antacids shouldn’t be taken at the same time as several other medicines, including some antibiotics, and food supplements (such as oral iron).
If heartburn occurs at least twice a week for at least four weeks, suggest trying an over-the-counter proton pump inhibitor (PPI) for 14 days to help reduce the production of stomach acid.
"OTC PPIs should only be taken for short-term treatment," says Julie Thompson. "Continuing symptoms should be reported to the GP. The incidence of side-effects, such as diarrhoea, headache, low magnesium and gut infections, is very small and for most people they are tolerated, but any side-effects should be reported."
Pharmacy customers should be advised that PPIs may interact with several medicines (e.g. digoxin, antifungals, protease inhibitors, methotrexate and warfarin). They can also mask symptoms of upper gastrointestinal cancers. If someone is taking a PPI and needs an endoscopy, the PPI should be stopped at least two weeks before the procedure. PPIs should be used with caution in people at risk of osteoporosis or low magnesium levels.
"If a patient is buying PPIs regularly, pharmacists should be giving lifestyle advice if appropriate," says Dr Sophie Nelson, a GP in Wilmslow, Cheshire and committee member of the PCSG, "then point them towards their GP to ensure there isn’t underlying pathology.
"Regular users of OTC PPIs will often have undiagnosed abdominal pain underlying this, and this could be anything – so ask these patients about weight loss and swallowing issues."
For dyspepsia in pregnancy, dietary and lifestyle advice are the first-line management approaches. If these fail to control symptoms, an antacid or an alginate may help. If this is ineffective or symptoms are severe, a GP may prescribe omeprazole.
According to NICE guidance, a GP should prescribe a PPI for four to eight weeks if patients have dyspepsia symptoms, with the length of course depending on the severity of the symptoms and whether or not GORD has been confirmed with an endoscopy. If the PPI doesn’t help, a GP may prescribe a different PPI, a stronger PPI dose or an H2 blocker instead. H2 blockers also stop the stomach producing too much acid but tend to be less powerful than PPIs.
Severe inflammation of the oesophagus (oesophagitis) should be treated with a PPI for eight weeks, taking into consideration patient preference, if there are any underlying health conditions and possible interactions with other medicines.
If the symptoms return after the patient has stopped taking the PPI, the GP should offer a PPI at the lowest dose possible to control ongoing symptoms and discuss taking the PPI only when needed, rather than regularly. Patients should have an annual review to reassess their symptoms and treatment. A 'step down' approach, or stopping treatment, should be encouraged, unless they have an underlying condition or are taking medicines such as NSAIDs that require continuing treatment. A return to self-treatment with antacid and/or alginates (over-the-counter or prescribed) may be appropriate.
H. pylori infections
If dyspepsia symptoms persist after a one-month course of PPIs and there are no alarm symptoms, testing for Helicobacter pylori bacteria might be an option. H. pylori, which live in the stomach, account for 95 per cent of duodenal ulcers and 70-80 per cent of gastric ulcers. The bacteria are also associated with acute and chronic gastritis, gastric cancer and gastric mucosa associated lymphoid tissue (MALT) lymphoma. People most at risk of H. pylori infection include the elderly, those of North African ethnicity, and those living in a known high-risk area.
H. pylori is usually detected with a breath or stool test and treated with a course of PPIs plus a combination of antibiotics, a so-called ‘test and treat’ strategy. Most people don’t need to be retested for H. pylori after treatment, but this may be necessary in some circumstances, for example if the symptoms persist or treatment compliance is poor. If retesting shows that H. pylori is still present, a second-line eradication treatment course may be prescribed.
Red flag symptoms
Long-term GORD can cause several complications, even if there is no specific underlying cause. Acid reflux may cause severe oesophagitis as well as ulceration, haemorrhage and stricture formation.
"It is especially important that patients seek medical attention urgently if they develop difficulty swallowing," says Dr Woodland. "A small proportion of people with long-term acid reflux have a change in the oesophagus called Barrett’s oesophagus. This carries an increased risk of oesophageal cancer."
In Barrett’s oesophagus, acid causes changes to the cells lining the lower part of the oesophagus. Ten to 15 per cent of people with GORD symptoms will develop Barrett’s oesophagus and, of these, up to 10 per cent will develop oesophageal cancer over the following 10 to 20 years. If someone has been diagnosed with Barrett’s oesophagus, they may need regular endoscopies to monitor it.
Customers should be referred to their GP if:
- They are unable to swallow
- Food gets stuck in their throat
- Significant acute gastrointestinal bleeding
- They are over 55 years of age with unexplained weight loss and symptoms of upper abdominal pain, reflux or dyspepsia.
Lifestyle changes can be effective
Although almost everyone suffers at some time from indigestion and heartburn, these problems can usually be fixed with simple lifestyle changes alongside effective pharmacy remedies, says Care brand manager Ruth Giles.
"Fortunately, there are many OTC treatments available to aid indigestion and heartburn, with most products aimed at neutralising acid or preventing its secretion," she says.
"Pharmacy teams should select the correct treatment based upon the individual’s symptoms. Antacids such as sodium bicarbonate powders can be recommended for the fast relief of symptoms. Other effective treatments include liquid magnesium trisilicate, which reduces excess stomach acid and helps break down and digest food.
"Eating a well-balanced diet, in particular smaller portions and keeping junk food to a minimum, alongside avoiding excess alcohol consumption, exercising regularly and reducing caffeine intake, are just some of the lifestyle changes pharmacy staff can recommend to patients to reduce the risk of heartburn and indigestion."
Trends in the OTC digestive health category
The overall digestive remedies category saw a small decline in 2021, according to a Euromonitor report on 'Digestive remedies in the United Kingdom'. This may be partly due to reduced sales of travel-associated products, and also because people may be eating more healthily when working from home because of Covid. However, antacids and proton pump inhibitors (PPIs) continued their growth trajectory.
"According to our internal space allocation data, the gastrointestinal category holds approximately 10 per cent of the total medicines category," says Cathy Crossthwaite, Numark OTC business development executive. "Within the heartburn and indigestion category, there are a wide variety of products available for self-selection. Additionally, there have been a few recent product launches and adjustments to the various sub-categories that have impacted the rate of sale within the wider category.
"These include the general move towards larger pack sizes across various divisions, as customers start to make fewer shopping trips and consider future need rather than just current requirements. What’s more, we now see indigestion products moving from Pharmacy-only medicines to the GSL classification, therefore improving self-selection, as the category continues to develop and grow."
It is useful to place fast-acting heartburn products, such as antacids, in prominent areas of the pharmacy such as the front counter unit, says Crossthwaite. "This will drive impulse purchases for those customers who are in search of quick relief on the go," she says.
"When merchandising the gastrointestinal category, lead with indigestion and heartburn as this is the most prominent sub-category and the one that customers are most likely to be seeking out. The category should cover a range of products to support common conditions that can be treated with OTC medicines, such as heartburn and indigestion, diarrhoea, constipation and haemorrhoids."