An estimated 60 million Americans experience heartburn at least once a month, and pharmacists need to be aware of the several classes of OTC products currently available to treat this common condition.
Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.
Statistics from the National Heartburn Alliance show that an estimated 60 million individuals experience heartburn at least once a month, and >50 million experience heartburn ≥2 days a week.1 In addition, an estimated 25 million individuals experience heartburn daily.1 Heartburn that an individual experiences within 2 hours after eating or when bending over or lying down is referred to as postprandial heartburn, whereas heartburn that occurs during sleep and is often responsible for waking an individual is referred to as nocturnal heartburn.2
Episodes of heartburn that are frequent and persistent (ie, ≥3 months) is the most common symptom of gastroesophageal reflux disease, which, if left untreated, can cause long-term complications, such as esophagitis, gastrointestinal bleeding, Barrett's esophagus, and esophageal cancer.2,3
A variety of risk factors may contributeto episodes of heartburn, including an individual's diet, lifestyle, the use of certain medications, and certain disease states.1-3 Pharmacists are key to identifying those pharmacologic agents or medical conditions that may increase an individual's risk of developing heartburn (see Table 1).
Several classes of OTC products can treat mild-to-moderate episodes of heartburn effectively, including antacids, histamine 2 (H2) receptor antagonists, a proton pump inhibitor, as well as combination products containing an H2 receptor antagonist and an antacid. In addition to these agents, bismuth subsalicylate, marketed as Pepto Bismol (Procter & Gamble), is indicated for the treatment of heartburn.
Antacids can be used to treat mild, infrequent heartburn, and indigestion. They relieve heartburn and dyspepsia by neutralizing gastric acid. OTC antacid products contain various salts, including magnesium salts (hydroxide, carbonate, and trisilicate), aluminum salts (phosphate and hydroxide), and calcium carbonate and sodium bicarbonate.2 They are available in a variety of flavors and formulations, including liquids and tablets. Three new antacid products on the market are GlaxoSmithKline's Tums QuikPak Instant Dissolve Powder, Tums for Kids, and Novartis Consumer Health's Maalox Antacid Barrier tablets. Tums QuikPak Instant Dissolve Powder dissolves without the need for water; Tums for Kids is appropriate for children aged 2 to 11.
Pharmacists should remind individuals taking agents such as tetracyclines, digoxin, iron supplements, fluoroquinolones, and ketoconazole that they should not use antacids within 2 hours of ingesting these agents; patients with impaired renal function should not use antacids containing aluminum and magnesium and should seek advice from their physician.2
OTC H2 receptor antagonists are indicated for the treatment of mild-to-moderate, infrequent, episodic heartburn and for the prevention of heartburn associated with acid indigestion and dyspepsia.2 These agents exert their mechanism of action by decreasing gastric acid secretion by inhibiting the effect of histamine on the H2 receptor of the parietal cell. They also decrease the volume of secreted acid and should be taken at the onset of symptoms or at least 30 minutes to 1 hour before symptoms arise.2 A new dosage form on the market includes chewable tablets available as Pepcid AC EZ Chews (Johnson & Johnson-Merck Consumer). Combination products that contain both an H2 receptor antagonist and an antacid appear to provide faster relief of heartburn.2
Pharmacists should screen for potential drug interactions and contraindications when recommending these products. For example, potential drug interactions for cimetidine include theophylline, antidepressants, phenytoin, and warfarin.2,4
Omeprazole is currently the only proton pump inhibitor available as an OTC product. It is indicated for the treatment of frequent heartburn in individuals who have heartburn for ≥2 days per week. It is not intended for immediate relief of occasional or acute heartburn episodes, however.2,5 It should be taken once daily with a glass of water in the morning at least 30 minutes before breakfast for 14 days. Patients should be advised to complete the full 14-day course of therapy. The tablet should not be chewed or crushed, and if symptoms still occur after completion of therapy or reoccur within 4 months, patients should be advised to seek medical care. Potential drug interactions associated with omeprazole include warfarin, ketoconazole, diazepam, digoxin, atazanavir, and tacrolimus.2,5
Pharmacists always should ascertain the appropriateness of self-treatment and screen for possible drug–drug interactions or contraindications before recommending any of these products. Individuals with preexisting medical conditions and pregnant or nursing women should be encouraged to seek advice from their primary health care provider prior to using any of these products. Pediatric patients <12 years of age always should be referred to their primary health care provider. It is essential for pharmacists to encourage individuals who experience severe symptoms associated with heartburn to seek medical care immediately to avoid further complications.
Patients using these OTC products should be counseled to seek immediate medical care if their symptoms worsen or show no signs of improvement after 14 days of treatment. It also is important to remind patients that these products should not be used for more than 2 weeks unless directed by a physician. When counseling patients on the appropriate use and adverse effects associated with the use of these products, pharmacists also can suggest possible nonpharmacologic measures, such as modifications to diet and lifestyle, including avoiding large meals and food or drinks that aggravate heartburn, as well as stopping or reducing smoking.