Upper GI problems
With digestive health one of the top five OTC categories in pharmacy, the after-effects of the customary over-indulgence in food and alcohol at this time of year offers a key opportunity to promote pharmacy’s role in the management of upper GI issues
After reading this feature you should be able to:
• Recognise the key symptoms of indigestion and heartburn
• Provide advice on OTC treatments and lifestyle measures to help customers manage these digestive disorders
• Spot the key early warning signs of potential GI cancers.
Dyspepsia is a blanket term describing a group of symptoms that indicate a problem in the upper GI tract — it is not a diagnosis in itself. Symptoms of dyspepsia include stomach pain or discomfort, heartburn, gastric reflux and nausea.
Indigestion falls under the broader banner of dyspepsia and occurs when there is an excess of acid in the stomach. This is usually caused by eating certain trigger foods or drinks such as coffee, alcohol, fizzy drinks, fatty foods or very spicy dishes. Indigestion can also result from eating excessive quantities of any food or by eating on the run and failing to chew food properly while ingesting excess air.
Indigestion is characterised by discomfort or pain in the stomach and is often accompanied by bloating, belching or nausea. In contrast, the hallmark symptom of heartburn is a burning sensation in the centre of the chest. Other symptoms can include a bitter/sour taste in the mouth caused by acid refluxing back into the throat, cough or recurrent hiccups, hoarseness and bad breath.
According to NICE, community pharmacists provide the frontline of care for dyspepsia sufferers and should be on hand to offer both initial help and ongoing advice. This should cover lifestyle measures, recommendations on OTC medications, help with prescribed drugs and advice on when to consult a GP.
Although heartburn and indigestion are everyday symptoms well suited to OTC management and an area where pharmacy teams can feel confident taking an active role, gastro-oesophageal reflux disease (GORD) is less clear cut. GORD can be difficult to pinpoint precisely as several different diagnostic definitions are in common use. NICE defines GORD as endoscopically determined oesophagitis or endoscopy-negative reflux disease and recommends treatment with full-dose proton pump inhibitors (PPIs), either as an eight-week course or as ongoing maintenance therapy.
Any patients with confirmed or suspected GORD should therefore be encouraged to consult their GP as this condition generally falls outside the OTC treatment domain. It is also important to be aware that GORD plays a possible role in the subsequent development of Barrett’s oesophagus, which is itself a risk factor for oesophageal cancer.
Tackling heartburn and indigestion
OTC antacids are the first-choice treatment for uncomplicated indigestion. As the name suggests, antacids contain one or more alkaline salts, which react with gastric acid to form water and carbon dioxide, thus neutralising the acid. This process of neutralisation also serves to make the stomach contents less corrosive, which can help to relieve the burning pain of heartburn.
Antacids get to work quickly but the relief they provide is short-term, so repeat dosing may be required. Liquid and powder formulations of antacids have a faster onset of action and greater neutralising capacity, but tablets may be preferred for their convenience and portability.
Alginates are another first-line option for heartburn and act as rafting agents to prevent the acid escaping from the stomach, thereby protecting the lining of the oesophagus. The active ingredients in alginates react with gastric acid to produce an alginic acid gel. Carbon dioxide then gets trapped within this gel forming a foam, which floats to the surface of the gastric contents.
A number of OTC indigestion remedies contain alginate and antacid ingredients together to combine the benefits of acid neutralisation and rafting. The optimal time to take antacids and/or alginates is when symptoms are expected to occur, for example with food or soon after eating, or at bedtime. Alginates are generally well tolerated with few contraindications but it is important to be aware of any additional antacid ingredients, such as sodium salts, which may restrict use in certain customers.
Proton pump inhibitors
For persistent heartburn symptoms that fail to respond to antacids or alginates, PPIs can be recommended. The PPIs omeprazole, esomeprazole and pantoprazole are approved for OTC use and work by ‘switching off’ gastric acid synthesis in the stomach lining.
These drugs start to suppress acid production within one to two hours of dosing and then build to maximum effectiveness after three to four days. Customers should be advised of this potential time lag (especially those used to the instantaneous action of antacids/alginates) and encouraged to continue treatment as directed.
PPIs are usually taken once a day, first thing in the morning. Once heartburn relief is achieved, PPIs should be discontinued as a short course of treatment is usually sufficient to give weeks of remission from recurrent attacks.
PPIs are very effective gastric acid reducers, so can impact on the bioavailability of other prescribed drugs by changing the pH in the stomach. Notable examples of potential interactions include erlotinib, triazolam, midazolam, glipizide, ketoconazole, atazanavir, delaviridine and gefitnib.
Close monitoring is also needed in patients taking concurrent warfarin and pharmacists should be aware that co-administration of PPIs with antibiotics increases the risk of Clostridium difficile up to three-fold.
In addition to pharmacotherapeutic options, there is a lot that customers can do themselves to help prevent or relieve symptoms of heartburn and indigestion. Lifestyle measures recommended to tackle heartburn and indigestion overlap considerably as these digestive symptoms usually have common triggers and often occur together.
The following simple self-care steps should be suggested for any customers suffering with symptoms of indigestion or heartburn:
- Lose weight if needed
- Try to identify particular foods or drinks that exacerbate symptoms and take steps to avoid them. Common culprits include rich, spicy and fatty foods, acidic foods, fizzy drinks, coffee and alcohol. Suggest that customers keep a daily food and drink diary and note down any specific triggers
- Cut down or try to stop smoking
- Avoid eating for at least three hours before bed
- Eat smaller, more frequent meals
- Eat slowly while sitting upright in a chair rather than slouched on the sofa
- Avoid clothes that fit tightly around the waist
- Make time for regular exercise and relaxation
- For heartburn specifically, lift the end of the bed by 10-20cms by placing something under the bed itself or the mattress. The aim is to raise the chest and head above the level of the waist so gravity prevents stomach acid from travelling up the oesophagus into the throat.
Antacid contraindications and interactions
Depending on the alkaline salt(s) that a specific product contains, there are a number of important contraindications and interactions that pharmacy teams should be aware of when recommending OTC antacids:
• Antacids containing sodium should be avoided in those on a salt-restricted diet, patients with impaired kidney or liver function, and pregnant women
• Calcium-containing antacids are not recommended for people taking thiazide diuretics
• A number of prescribed medications including some antibiotics, anticonvulsants, antirheumatics and antifungals can also interact with antacids, so it is important to check the individual product details first. Taking other medicines within two to four hours of antacid or alginate dosing should be avoided.
It is important to be alert for medicines that can potentially cause or exacerbate indigestion/heartburn symptoms. Classes of drug to be aware of include calcium antagonists, nitrates, bisphosphonates, corticosteroids, NSAIDs, aspirin, iron, opiates, metformin, theophylline, anticholinergics and tricyclic antidepressants.
For some customers, heartburn and indigestion can prove recurrent, long-term issues which will require prescription strength medication to control. Pharmacy teams can help this group of patients with ongoing support to optimise their medications as well as counselling on beneficial lifestyle changes and interventions.
NICE advises that people who require long-term management of dyspepsia symptoms are told to reduce their use of prescribed medication stepwise as much as possible. This may be achieved by using the lowest most effective dose, trying ‘as needed’ use when appropriate, and/or by returning to self-treatment with antacid and/or alginate therapy where possible.
The H2 antagonist ranitidine works by binding to histamine receptors in the stomach lining, therefore reducing activation of the proton pump and cutting gastric acid production.
Despite being a stalwart of pharmacy medicine shelves for many years, ranitidine was withdrawn last year subject to an ongoing investigation about potential links to increased cancer risk.
Customers seeking H2 antagonists should be advised that ranitidine is not currently available in the UK and alternative options like proton pump inhibitors (PPIs) recommended instead.
Spotting early signs of cancer
Although the vast majority of indigestion, heartburn and other GI symptoms will have a benign aetiology, it is important for all pharmacy staff to be vigilant for signs and symptoms of potential cancer. When any customer presents with these red flags, it is important to strike a delicate balance between not causing undue alarm but nonetheless encouraging the person to get their symptoms checked out expeditiously by a GP.
The most common presenting symptom of oesophageal cancer is difficulty swallowing (dysphagia). Customers may complain of a painful or burning sensation when they swallow or describe the feeling of food ‘sticking’ in their throat or chest. This can be particularly obvious when eating foods such as meat, bread or raw vegetables.
Persistent heartburn or indigestion is another potential sign of oesophageal cancer if the tumour is located lower down in the oesophagus and affecting the cardiac sphincter valve that regulates flow of food into the stomach. Some patients also report pain behind the breastbone or more rarely in the back behind the shoulder blades, which can be exacerbated by swallowing or during bouts of indigestion.
A key early symptom of stomach cancer is feeling full after eating only small amounts. Bleeding into the stomach can also occur early in the disease causing faeces to appear darker and, over time, anaemia to develop accompanied by fatigue and breathlessness.
Many of the other signs and symptoms of stomach cancer overlap with those of oesophageal cancer including dysphagia, persistent indigestion and pain behind the breastbone. If the stomach becomes blocked by the tumour, nausea or vomiting may also occur.
Spotting early signs of small bowel cancer is difficult as signs and symptoms are often vague and mimic those of everyday conditions such as IBS. As with many of the other GI malignancies, potential indicators of small bowel cancer include stomach pain or cramps, a lump in the abdomen, nausea and vomiting, diarrhoea, fatigue, dark black faeces and anaemia.
Pancreatic cancer onsets insidiously and rarely causes symptoms in the early stages. Once the cancer starts growing, the key symptoms to look out for include pain in the stomach area or back (affecting 70 per cent of patients at presentation) and jaundice (found in one in 10 sufferers).
Pain associated with pancreatic cancer has hallmark characteristics, with patients describing it as a dull pain that feels as though it is boring into the body. It often begins in the stomach and spreads into the back, is worse when lying down, relieved by sitting forward and can be exacerbated by eating. Some patients with pancreatic cancer report back pain only, which tends to be centred and persistent.
Unexplained weight loss is a red flag symptom that spans all different types of cancer but can be a particularly pertinent early sign of GI cancers where swallowing, appetite and food absorption can all be affected. Any customer with unexplained weight loss requires urgent referral to their GP for further investigation as this can also be an indicator of advanced cancer.
Harmless strictures in the oesophagus are a key cause of dysphagia so it is important to offer reassurance while also encouraging any customer with this symptom to consult their GP. Similarly, symptoms of stomach cancer can mimic those of less serious conditions such as peptic ulcers. Current advice from the NHS is to seek further medical advice if heartburn is present on most days for three weeks or more, even if relief is obtained with OTC treatments.
Patients should also be advised to consult their GP if they are suffering from intractable indigestion (particularly if aged over 55 years), severe pain, a lump in the stomach or blood in the vomit or faeces. As a guiding principle, Cancer Research UK advises anyone “to see your doctor if you have unexplained weight loss or symptoms that are unusual for you or that won’t go away”.
With any potential cancer symptoms it is also important to put things into clinical context by considering any underlying risk factors that an individual customer may have. Key risk factors for GI cancers include older age, being overweight or obese, smoking and excess alcohol consumption.
Safely recommend the most effective laxative for every customer with constipation