Pharmacists are well-placed to help patients manage this common – but uncomfortable – condition, say Stephen Attwood and Hasan Haboubi
Acid reflux symptoms are very common – up to 20% of individuals may suffer from them. Many people can manage these symptoms safely and effectively with the assistance of their community pharmacist. People on long-term medication with good control of symptoms are often left on medication for many years, but it is worthwhile reinforcing lifestyle modifications and checking every so often that the medications are still needed, and emphasising that it is worth trying ways to step down or stop the medications.
Spotting acid reflux when talking with patients
When someone describes a burning discomfort or pain that seems to arise in the lower chest, behind the breastbone or from upper middle abdomen, moving upwards, they may be suffering acid reflux.
The person may also complain of food or bad-tasting fluid moving upwards from their abdomen into the upper chest or their throat. This is known as regurgitation. The third typical symptom of reflux is the sensation of discomfort in the lower chest when swallowing (dysphagia if food sticking or odynophagia if swallowing is painful).
These symptoms can be triggered by a number of factors, often occurring after eating, bending forward or at night when lying down.
Community pharmacists should take care when advising patients with such symptoms to not assume reflux if someone describes indigestion, because the latter condition has a variety of other causes. Similarly, the medical term dyspepsia is also non-specific and often unhelpful. It is thus always best to focus on what the patient is actually feeling before jumping to any conclusions.
Causes of acid reflux
The underlying cause of reflux is often not known. During reflux episodes, the material in the stomach moves into the lower oesophagus across a junction (sphincter) that should have an effective barrier. The material from the stomach contains acid, which causes symptoms of pain and sometimes causes erosion of the lining of the oesophagus (oesophagitis). The acid is often mixed with enzymes, partially digested food and sometimes even yellow bile.
The barrier between stomach and lower oesophagus tends to be ineffective in people with a hiatus hernia (where part of the upper stomach moves through the diaphragm into the chest cavity), but can occur without a hiatus hernia.
Inappropriate relaxation of the sphincter at the lower oesophagus may start to occur at any age without a hernia, and symptoms often begin following meals but can progress to any time of day – even waking the sufferer at night. Some very specific medical conditions are associated with reflux, such as rheumatoid arthritis or other similar diseases, and some patients with asthma or chronic breathing disorders can also suffer with acid reflux.
Lifestyle/other clinical factors contributing to acid reflux
Obesity, smoking and being pregnant are common promoters of reflux. Eating fatty foods, chocolate or drinking caffeine, which both lower the pressure in the sphincter, are important contributors. Additionally, white wine, fizzy or acidic drinks and eating large meals can aggravate the problem. Although commonly accused of being causative, there is no clear evidence that spicy foods are harmful or causative of reflux. However, if the sufferer recognises an association, then avoiding them seems sensible.
Advice to give to patients
Reducing weight and stopping smoking are both really worthwhile – because they have additional benefits – but may require a co-ordinated effort with assistance from the pharmacist, GPs and other healthcare professionals. Patients may also find symptomatic relief from wearing loose belts and clothing.
Dietary advice should also be aimed at avoiding exacerbating foods, reducing the size of meals and eating the evening meal earlier if possible – at least three to four hours before lying down. Raising the head of the bed on blocks may offer additional symptomatic relief, but on its own may not be useful.
What to avoid
Adjusting the diet to lower fatty food intake, especially chocolate and animal fats, and avoiding carbonated drinks, beer and white wine will help reduce symptoms, although may not cure the problem. Smoking cessation is also an important lifestyle change for a multitude of reasons.
Tips for patient self-care
Initial treatment depends on the severity and frequency of the symptoms. If mild, then simple lifestyle measures alone may suffice. If severe, and especially if disturbing normal activities more than twice a week, then an antacid mixed with alginate (such as Gaviscon) is very effective if taken immediately after meals. Initially, they probably work best when taken before the symptoms have begun. In other words, they should initially be used regularly before each main meal for a few days and then adjusted depending on the patient’s improvement.
If these do not work within a few days, the sufferer may need medication, usually a proton pump blocker such as omeprazole, pantoprazole or other similar preparations. For a new patient with these symptoms, these are best prescribed by their GP. A full course should be taken before a decision is taken on long-term treatment. Other medications that some patients enquire about, such as Histamine antagonists (Rantitidine, etc), are considered less effective than PPIs and are not routinely prescribed.
Pharmacists should ask about other medications, such as treatments for osteoporosis (especially bisphosphonates), which can cause severe reflux-type symptoms in elderly patients, and refer patients to their GP for alternatives if appropriate.
Social circumstances and causes of stress are additional factors worth investigating and addressing, as these can be underlying or aggravating factors.
All patients should be encouraged to lose weight and stop smoking whether they are being medicated or not.
When to see your doctor
Where there are severe symptoms, new symptoms occurring in someone aged over 55 (with no previous similar problems), or if the patient reports discomfort swallowing or food sticking, a referral to a doctor – and usually a subsequent endoscopic examination – is required. If the patient reports weight loss, vomiting with blood, anaemia, dark tarry stool (melaena), or other associated serious symptoms then urgent referral is recommended. If patient self-care and antacids have worked for a while but symptoms persist, then referral to the GP is also worthwhile.
What are the options in treatment?
Long-term proton pump medication may be required. These are highly effective in 60% of patients and partially effective in an additional 20%. For a small number, even these may not be sufficient, and various procedures are available to improve the function of the barrier between the oesophagus and stomach, including endoscopic and keyhole surgical procedures.
There is a growing list of technologies used. Pharmacists should be aware of the terms Radiofrequency Ablation (RFA), endoscopic or surgical fundoplication (the latter also including repair of hiatus hernia), and alternative new surgical approaches including magnetic bead bands (LINXTM device) or electrical neuromodulation of the lower oesophageal sphincter (EndoStim device). Information about all of these is available online and may be something the patient has read about.
Newer medications are also being evaluated, such as potassium-competitive acid blockers (Takecab or vonaprazan), but these are yet to be approved for use in the UK.
Questions about such therapies are best discussed with the patient’s GP and are rarely brought up in the early stages of reflux symptoms. But if the problem has persisted or progressed for a few years, then patients often seek alternative approaches through specialist services.
What to do when treatment is not working
If initial advice does not help, either the treatment is insufficient or possibly the diagnosis is incorrect. Patients often describe their symptoms as heartburn or indigestion without clearly understanding how these are interpreted by medical or paramedical professionals. It is thus always worthwhile to double-check exactly what the patient is describing, because if they suffer nausea and a bloating sensation, these are not usually related to reflux, although they can occur along with it.
There are many alternative causes of these symptoms. If they occur with a change in bowel habit, they may be part of the spectrum of irritable bowel syndrome, which often has overlap with reflux-type symptoms. If abdominal pain is predominant, then a peptic ulcer may exist. If occurring regularly after meals in the upper abdomen, then gallstones may be present. If bloating is predominant, then testing for bacterial overgrowth in the small intestine (using hydrogen and methane breath testing after a challenge meal) may reveal an alternative diagnosis. In short, if treatment fails, it is worthwhile seeking medical attention.
If discomfort in swallowing or a feeling of food sticking in the chest persists even after initial medical assessment, further tests may be needed. Samples taken from the lining of the oesophagus may show eosinophilic inflammation, which is usually not reflux-related and requires a completely different approach, supervised by a doctor.
1 Badillo R, Francis D. Diagnosis and treatment of gastroesophageal reflux disease. World Journal of Gastrointestinal Pharmacology and Therapeutics 2014;5:105-12.
2 Boeckxstaena G, Rohof W. Pathophysiology of gastroesophageal reflux disease. Gastroenterol Clin North Am 2014;43:15-25.