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Heartburn, the hallmark symptom of gastroesophageal reflux disease (GERD), is a monthly occurrence for approximately 44% of Americans. With 18% of patients using medications for heartburn 2 times per week, pharmacists have an opportunity to actively promote the safe and effective use of both prescription and nonprescription therapies.1,2 A stepwise approach that addresses a patient's medical and social history can be employed to successfully guide those seeking self-treatment through the maze of nonprescription options.
Identification of Candidates for Self-Directed Treatment
The identification of appropriate candidates for self-treatment is the first objective of the pharmacist?patient interaction. According to the American College of Gastroenterology, nonprescription therapies are most appropriate for patients reporting episodic symptoms for <4 weeks. Those with frequent severe symptoms or complaints of dysphagia, bleeding, weight loss, choking, or chest pain should not attempt self-treatment. Patients experiencing symptoms during pregnancy or while taking nonsteroidal anti-inflammatory drugs also should be referred for further evaluation. Prompt referral will enable early identification of severe disease, which if left untreated can progress to erosive esophagitis, Barrett's esophagus, or adenocarcinoma.1,2
In addition, symptoms suggestive of myocardial infarction? such as chest pain accompanied by dizziness, nausea, or sweating?may mimic those of GERD and cause the patient to falsely seek treatment for heartburn.2 By obtaining an abbreviated medical history, the pharmacist can quickly identify patients with complex symptoms requiring referral.
Once an appropriate candidate for self-treatment has been identified, drug selection can be guided by the patient's symptom pattern. All nonprescription options are acid-modifying agents that counteract one component of the primary cause of heartburn, the esophageal irritation caused by the reflux of acidic gastric contents. Agents that affect other components of GERD symptoms, such as gastrointestinal motility and lower esophageal sphincter (LES) tone, are not available in nonprescription formulations. Infrequent symptoms often can be managed with antacids and/or histamine2 (H2) receptor antagonists, which have been shown to provide relief in 60% to 70% of users.1,2
Antacids are available in a wide variety of formulations and typically provide immediate relief for patients with infrequent but unpredictable symptoms. Despite the response, their use is typically limited by the short duration of effect. Predictable symptoms, such as those experienced after a heavy meal, may be prevented by using the longer-acting H2 receptor antagonists, which are available in non-prescription formulations as cimetidine, ranitidine, famotidine, and nizatidine. These drugs can be given alone or in combination with antacids to offer the benefit of both a quick onset and a longer duration of symptom relief.
Despite the extended coverage, patients experiencing frequent symptoms, defined as occurring 2 days per week, may have difficulty managing the frequent dosing required to achieve prolonged acid suppression with either of the above options. A once-daily alternative is now available with the recently approved product, omeprazole magnesium (Prilosec OTC).
The nonprescription proton pump inhibitors (PPIs) offer an alternative for patients with uncomplicated but more frequent GERD symptoms. They expand on the conventional use of prescription-only PPIs for the treatment of moderate-to-severe erosive and nonerosive disease. The longer duration of effect allows for convenient daily dosing intended for a 14-day course, but the longer onset precludes their use for intermittent, episodic relief. Thus, examination of the frequency of symptoms is essential when individualizing therapy recommendations.
Upon selection of the regimen warranted by the patient's symptom pattern, the patient's medication history should be screened for any pertinent drug?drug interactions. Common antacid interactions include those with fluoroquinolones, tetracyclines, and iron preparations. Although most of the nonprescription versions of H2 receptor antagonists contain no warnings about drug?drug interactions, product labeling for cimetidine (Tagamet HB 200) lists potential interactions with theophylline, warfarin, and phenytoin. The labeling for Prilosec OTC identifies potential interactions with warfarin, antifungals, diazepam, and digoxin. It should be emphasized that these labeled drug interactions apply to the use of the products at the nonprescription dose, frequency, and duration, which differs from prescription regimens often given at higher doses for longer use.
Monitoring the Response to Therapy
Regardless of the chosen therapy, appropriate self-treatment of mild GERD symptoms requires careful monitoring of response. Because the timing of administration is product-specific and crucial to achieve maximal relief, it is important to verify adherence to the directions for use when a patient reports little benefit upon follow-up. If the products are used correctly, however, and symptoms worsen or are not relieved by a 2-week treatment, patients should be referred to their physician for further evaluation. Patients who require doses above the labeled recommendations or combined therapy with H2 receptor antagonists and a PPI to achieve symptom relief also should be evaluated for the need for additional diagnostic testing and prescription modalities.
Patients may find the use of symptom diaries helpful in identifying improvement as well as individual triggers. Examples of symptom diaries are available from various organizations such as the National Heartburn Alliance (www.heartburnalliance.org) and the American College of Gastroenterology (www.acg.gi.org).
Management of Symptom Triggers
Modification of food, medication, and lifestyle symptom triggers always should be encouraged as an adjunct to medication use. These measures may limit the frequency and severity of symptoms as well as the need for acid-suppressive medications. Lifestyle changes such as smoking cessation, weight loss, and avoidance of postprandial recumbency can have a positive impact on symptoms, as can limiting the intake of high-fat, caffeine-containing, and acidic or spicy foods.
Pharmacists can help to identify potential alternatives to medications that negatively affect LES pressure or gastric emptying time?such as anticholinergic agents, theophylline, nitrates, tricyclic antidepressants, and opiates. The correct use of medications that potentially irritate esophageal mucosa?such as bisphosphonates, aspirin, iron, and potassium supplements?also can be emphasized.
GERD symptoms can significantly impair quality of life by affecting social activities, sleep, diet, and activity level. By identifying appropriate candidates for self-treatment of GERD symptoms, matching medication recommendations to symptom frequency, and encouraging symptom-trigger management, pharmacists can enable patients to become active participants in the safe and effective treatment of mild symptoms.
Dr. Raney is an assistant professor of pharmacy practice at Midwestern University College of Pharmacy?Glendale, Glendale, Ariz.
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