Upper gastrointestinal disorders are widespread but remain poorly understood by the public. So what can pharmacists do to equip patients with the necessary knowledge to take control of their symptoms?

What is the difference between indigestion/dyspepsia, heartburn, acid reflux and GORD?

People often confuse the symptoms of upper gastrointestinal (GI) disorders, but according to the gut and liver disease charity, Core, indigestion or dyspepsia refers to pain or discomfort in the upper abdominal area after eating, while heartburn refers to the burning pain felt behind the sternum associated with acid reflux, which is often accompanied by nausea, water brash or regurgitation of acid or bile.

Dyspepsia usually occurs when stomach acid irritates the stomach lining, oesophagus or top part of the bowel, perhaps after a heavy meal, whereas most cases of acid reflux or gastro-oesophageal reflux disease (GORD) occur due to weakening of the lower oesophageal sphincter.

“GORD is caused by acid leaking up from the stomach and coming into contact with the oesophagus. While the stomach is able to withstand litres of acid without pain, the gullet is not,” explains Core medical director, Dr Anton Emmanuel. “GORD is clearly definable, while dyspepsia is more nebulous. It can have various causes, such as a blockage in the bowel, an ulcer or a problem with the pancreas.”

What is the burden of upper GI problems?

There are many statistics regarding upper GI problems. For example:

• NICE Clinical Knowledge Summaries estimate that between 20 and 40 per cent of the population suffer from dyspepsia
• According to NHS Choices, one in five people experience at least one episode of GORD a week, with one in 10 affected on a daily basis
• A systematic review published in Gut in 2005 found that heartburn and indigestion account for 5 per cent of all GP consultations. The review also highlighted the impact of GORD on quality of life and productivity, with sufferers reporting impaired sleep and interference with social activities and work
• According to NHS Choices, acid reflux affects both men and women equally, but Patient UK says it is two to three times commoner in men.

Why are upper GI problems becoming more prevalent?

Although dyspepsia and acid reflux are distinct conditions, they can have similar triggers, including certain foods, alcohol, caffeine, stress, being overweight or obese and certain medications. Unsurprisingly the rise in unhealthy lifestyles and obesity is contributing to a rise in prevalence of both problems.

“Incidence of GORD is rising as we are getting fatter as a population and carrying more weight around our middles, which puts pressure on the abdomen and causes the stomach contents to rise,” explains Dr Emmanuel. “In addition, people are binge drinking and eating more fatty or calorific food, which increases acidity levels.”

Prescribing has increased for cardiovascular drugs, such as calcium channel blockers and nitrates, as well as non-steroidal anti-inflammatory drugs (NSAIDs), steroids and selective serotonin reuptake inhibitors (SSRIs). These medicines can have the side-effect of relaxing the lower oesophageal sphincter and allowing stomach acid to pass upwards into the oesophagus.

How can symptoms be managed through lifestyle changes?

Certain lifestyle modifications can help to ease the severity of symptoms of GORD and dyspepsia, although many patients will also need to take medication. For example, eating smaller, more frequent meals can help to control reflux and indigestion by reducing pressure on the abdomen, as can avoiding dietary triggers, such as coffee, alcohol, citrus fruits, chocolate and fatty foods. These may relax the lower oesophageal sphincter and/or delay gastric emptying.

Giving up smoking may also help, as smoking can exacerbate GORD symptoms by relaxing the lower oesophageal sphincter. Losing weight if overweight or obese should also help to control symptoms, but sufferers should avoid over-exertion and exercises like sit-ups, as these can provoke acid reflux.

The symptoms of GORD are often worse at night, especially for overweight individuals, but raising the head of the bed by 20cm by placing blocks underneath it may help. Propping the head up with pillows is not advisable as this may put extra pressure on the abdomen. It may also be beneficial to avoid wearing tight clothes, stooping or bending forwards.

Managing stress may also help to reduce symptoms, says Dr Emmanuel. “Stress is a contributing factor as it can increase acid production by affecting the motility function of the digestive tract, interfering with its rhythmic movements.”

Pharmacists should advise on appropriate PPI use

What are the long-term health risks of chronic acid reflux?

While the majority of GORD sufferers will not experience any complications, repeated exposure of the oesophagus to acid can cause damage in some individuals, such as oesophageal ulcers, stricture and, rarely, Barrett’s oesophagus. Ulcers may bleed, causing pain and swallowing difficulties (dysphagia), while a stricture can make swallowing food difficult and painful.

Barrett’s oesophagus occurs due to changes in the cells of the gullet lining, which can make it more predisposed to tumours. However, according to Dr Emmanuel, “less than 1 per cent of people with Barrett’s oesophagus develop cancer”.

Why is acid reflux common in pregnancy?

Pregnancy is a strong risk factor for acid reflux for two reasons:

• Hormones released during the first trimester can have a relaxing effect on the lower oesophageal sphincter
• During the latter stages of pregnancy the developing baby can put increased pressure on the abdomen.

Women who have previously suffered from GORD are more likely to experience it during pregnancy than those who have not, but symptoms usually return to normal after birth. Dyspepsia symptoms like bloating and feeling full quickly after eating are also common in pregnancy.

What are the main treatment options for GORD and dyspepsia?

Alongside lifestyle measures and reviewing medication, the first-line treatment options for mild to moderate GORD and dyspepsia are antacids and alginates.

Antacids are alkali liquids or tablets that provide immediate relief by neutralising excess stomach acid, although the effects are often short-lived so extra doses may be needed. Care should be taken to avoid taking antacids alongside other medicines, as they can interfere with absorption or damage the coating of certain tablets. Alginates protect the oesophagus by forming a barrier or ‘raft’ over the top of the stomach contents, helping to suppress the backflow of acid.

Antacids and alginates are available in combination to provide dual action relief against both heartburn and indigestion.

For patients with persistent symptoms that are not relieved by antacids or alginates, acid suppressants are available, including histamine H₂ receptor antagonists (H₂ blockers) and proton pump inhibitors (PPIs).

H₂ blockers, such as cimetidine, famotidine, nizatidine and ranitidine, prevent the parietal cells in the stomach from responding to histamine by releasing acid.

PPIs, such as lansoprazole, omeprazole, pantoprazole, rabeprazole and esomeprazole, are more commonly prescribed or recommended for managing GORD than H₂ antagonists, and are also used to treat H. pylori infections. They work by reducing the production of stomach acid by inhibiting the hydrogen-potassium adenosine triphosphatase enzyme system, otherwise known as the ‘proton pump’. This reduction in acid reduces reflux symptoms, helping to heal the oesophagus as well as ulcers in the stomach or duodenum.

What are the problems of long-term PPI use?

While PPIs are well tolerated in most individuals and can have a big impact on quality of life, overuse can lead to complications. “PPIs have the tendency to be overused,” says Dr Emmanuel. “Long-term use can lead to both osteoporosis, because the reduced acidity can inhibit calcium absorption, and more rarely, gastric polyps.”

PPI prescribing has risen considerably in recent years. An audit of three north Lancashire general practices carried out in 2012 revealed that these drugs were being prescribed to around 8 per cent of all patients (see case study, previous page). PPI use is also strongly associated with polypharmacy, with the majority of patients in the audit being prescribed four or more medicines. In 2011, more than 40m PPI prescription items were dispensed across England and Wales, with omeprazole and lansoprazole achieving the fifth and tenth position respectively in the list of most dispensed items in the community.

NICE guidance recommends that PPI use should be reviewed annually with the aim of returning to self-care with antacids and/or alginates.

Dr Emmanuel believes that community pharmacists could have an important role in reducing unnecessary PPI use in accordance with the latest NICE guideline on dyspepsia.

“Around 45 per cent of patients taking PPIs don’t need them,” he says. “What happens is that they are prescribed them for a fortnight when symptoms are bad but when they stop taking them, they experience rebound hyperacidity, which causes them to start taking them again. It can be very helpful for pharmacists to highlight the problem, to talk through symptoms with their patients and ask why they are taking PPIs.”

In many cases, patients can get adequate symptom relief from antacids and alginates, especially if they are experiencing regurgitation. However there is a strong perception that antacids and alginates are less powerful than PPIs, which pharmacists could help to overcome.

Clinical audit: Preventing GI bleeds

A new clinical audit has been added to PharmOutcomes to help community pharmacists identify patients at risk of gastro- intestinal bleeds.

Developed by the NHS East & South East England Specialist Pharmacy Services (SPS) medicines use and safety team, and available to all contractors in England, the easy-to-complete audit is designed to improve patient safety and strengthen the evidence for pharmacy interventions.

A pilot of the audit in five community pharmacies found that nearly one-third of patients who had been taking NSAIDs regularly for more than two months were not taking any gastro-protection, including two patients over 75 years who were at increased risk of a GI bleed.

“If these results are seen in other pharmacies, there is a significant improvement in patient safety to be made using a quick and simple intervention, which could provide powerful evidence of the value of community pharmacy’s role as a safety net in the medicines pathway,” said Dr Carina Livingstone, associate director, medicines use and safety.

Are there any other treatment options?

If other treatments fail to provide relief from upper GI symptoms, GPs may prescribe a short-term course of prokinetics, such as domperidone and metoclopramide. These speed up the emptying of the stomach contents so there is less opportunity for the acid to irritate the gullet. These medicines are particularly effective if the patient has marked belching or bloating symptoms.

Prokinetics have been associated with extrapyramidal symptoms in a small number of individuals, especially people under 20 years of age, but these usually subside within 24 hours of stopping the medication.

Surgery is usually only recommended in cases of GORD that fail to respond to drug treatments. Laparoscopic nissen fundo- plication (LNF) is one of the commonest surgical techniques used to treat GORD. However a number of new, non-invasive surgical techniques have been developed over the past decade, including the endoscopic injection of bulking agents, augmentation with hydrogel implants and radiofrequency ablation.

In addition there are trials currently taking place looking at alternative drugs that act on the lower oesophageal sphincter rather than on stomach acidity but these are likely to be many years away from development.

The rise in upper GI complaints is closely linked to our increasingly unhealthy lifestyles

What symptoms require referral and further investigation?

Patients should be referred to their GP if they are having frequent or severe symptoms and relying on OTC medication on a weekly or daily basis. NICE guidance lists red flag symptoms that require urgent referral as:

• Persistent indigestion for the first time in people over 55 years of age
• Passing blood or black, tarry stools
• Vomiting blood
• Progressive, unexplained weight loss
• Difficulty swallowing
• Persistent vomiting
• Progressive dysphagia.

 

Incidence of GORD is rising as we are getting fatter as a population