Author: Rupal Patel Mansukhani, PharmD, and Mary Barna Bridgeman, PharmD, BCPS, CGP
Case 1—Frequent Heartburn
JM is a 44-year-old woman who has used an OTC acid suppressive medication like famotidine or ranitidine for as-needed relief of occasional heartburn. Over the past 3 weeks, her symptoms have been occurring more frequently, to the point where she currently experiences heartburn 3 to 4 days per week. She attributes this increase to a recent promotion at work that has necessitated more frequent travel, poor eating habits, and a lot of stress. She asks if you can recommend an alternative therapy that might work better than the acid suppressive agents. She has no known allergies and currently takes fluticasone propionate (Flonase), loratadine (Claritin) for allergic rhinitis, and a daily multivitamin. What would you suggest to alleviate her symptoms?
Heartburn can be classified as either infrequent or frequent, depending on the number of episodes a patient experiences each week; frequent heartburn is characterized by the occurrence of heartburn symptoms on 2 or more days per week, whereas infrequent heartburn occurs fewer than 2 days per week.1
JM would likely benefit from nonpharmacologic lifestyle modifications, such as practicing stress-relieving techniques and avoiding “trigger” foods that can exacerbate her condition (eg, alcohol, caffeine, spicy or citrus foods).
receptor antagonists (H2
RAs) are preferred therapies for patients with mildto- moderate infrequent heartburn symptoms due to their rapid onset and longer duration of effect than antacid treatment. For patients like JM with frequent symptoms or symptoms that are not relieved by H2
RA treatment, a nonprescription proton pump inhibitor (PPI) such as omeprazole should be considered.
Although OTC PPIs do not provide the same rapid relief as nonprescription antacids or H2
RAs, these agents have a much longer duration of acid suppressive effect and may offer superior symptomatic relief for the patient experiencing frequent symptoms.
Remind patients that when they self-treat with a PPI, treatment is generally limited to a 14-day course of treatment that should not be repeated more often than once every 4 months. If her symptoms are not improved after a 2-week course, it may be prudent to instruct JM to follow up with her primary care provider to rule out a more serious gastrointestinal condition.
Case 2—Hangover Helper
PL is a 29-year-old man who reports a burning sensation in his midchest that seems to radiate up to his neck. These symptoms started after a night of binge drinking the previous evening. He describes having difficulty falling asleep because the symptoms kept him awake and says he’s “just looking for some quick relief.” He reports that he’s only experienced these symptoms before approximately 1 month ago after a night out with the guys. He is otherwise healthy, has no known allergies, and is not taking any other medication. Is PL a candidate for self-treatment? What OTC agent would you recommend to relieve his symptoms?
PL’s acute, infrequent dyspepsia is related to his overindulgence in alcohol, a common trigger for heartburn and dyspepsia. He describes symptoms that are mild to moderate in nature and he does not describe anything that would warrant physician referral (eg, symptoms occurring 2 or more days per week for more than 3 months; heartburn that persists 2 weeks or longer after self-treatment with an OTC acid suppressive medication or that occurs during such therapy; severe symptoms, dysphagia, or difficulty swallowing foods; vomiting blood or passing dark stools).1
Recommend that PL use either an antacid or an H2
RA like famotidine for symptom relief, as these agents have a rapid onset and will give him the most immediate relief. If he is concerned about symptom recurrence, another option would be a combination antacid and H2
RA product. The advantage to this type of product would be the quick onset of the antacid (usually effective at mitigating dyspepsia symptoms within 5 minutes) coupled with the sustained relief (up to 8-10 hours) of the longeracting H2
Dr. Mansukhani is a clinical pharmacist in South Plainfield, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University. Dr. Bridgeman is an internal medicine clinical pharmacist in Trenton, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University.
1.Heartburn and Dyspepsia. In: Krinsky DL, Berardi RR, Ferreri SP,et al (eds). Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 17th
edition. Washington, DC: American Pharmacists Association, 2011, pp.219-235.