Pharmacist Approach to Heartburn, continued. Figure 4 Risk factors that may contribute to Heartburn 5 Alcohol can: 1 - increase the relaxation of the lower esophageal sphincter (LES). Gastric acid can then reflux into the esophagus when it normally would not, thereby irritating the esophageal wall; 2 - cause the progressive contractions that occur with swallowing to become erratic. An irregular rhythm can allow acid to enter the esophagus or impair its clearance, thereby triggering heartburn symptoms; 3 - increase the amount of acid produced in the stomach; and 4 - make the esophagus more sensitive to acid and cause inflammation or swelling in its protective lining. Pregnancy: Heartburn may affect pregnant women due to the effects of progesterone levels on the LES. Pregnancy hormones slow the entire digestive process leading to indigestion and other gastrointestinal problems that may exacerbate heartburn. The crowding of internal organs from the expanding uterus may force stomach fluids up, in a retrograde manner, into the esophagus. Obesity: increases intra-abdominal pressure and promotes reflux of acidic gastric contents into the esophagus, resulting in heartburn. Fat: relaxes the LES and delays gastric emptying; both of these factors may promote reflux causing heartburn. Medications: Anticholinergics, caffeine, ethanol, calcium channel blockers, nicotine and opioids lower LES pressure. Other medications such as bisphosphonates, ASA, clindamycin, NSAIDs, potassium salts and Iron are direct irritants. Stress: is not a direct cause, but leads to trigger behaviors that may aggravate heartburn and other conditions. Tobacco use: Smoking can reduce the effectiveness of the LES and slow the production of saliva which helps neutralize stomach acid that has refluxed into the esophagus. Patients may initially prefer to self-medicate, with or without professional advice. The opportunity for patients to speak with a pharmacist may yield medication or non-medication (life-style) solutions or it may lead to a referral to another professional. It is hoped that pharmacists will access evidence-based medication and therapeutic guidelines to provide best care to their patients. One example of objective comparative drug information can be found through the academic detailing program RxFiles.ca6 If the patient has been assessed by the pharmacist, there are 3 options to discuss with the patient - referral to another healthcare provider, recommendation of a non-pharmacological treatment or recommendation of a pharmacological treatment. The pharmacist may need to refer the patient to another healthcare practitioner if the patient has any of the risks or warning signs for Gastroesophageal Reflux Disease (GERD) or its complications (Figure 5). Figure 5 Referral considerations for GERD 1 The pharmacist may indicate to the patient the benefit from non-pharmacological treatment options. For lifestyle modification (Figure 6), broadly speaking, there are 3 categories: 1. Avoidance of foods that may precipitate reflux (e.g., coffee, alcohol, chocolate, mint, fried or fatty foods) 2. Avoidance of acidic foods that may precipitate heartburn (e.g., citrus, tomato, garlic, onions, carbonated drinks, spicy foods) 3. Adoption of behaviors that may reduce esophageal acid exposure (e.g., weight loss, smoking cessation, eating smaller more frequent World Digestive Health Day WDHD May 29, 2015 WGO HANDBOOK HEARTBURN: A GLOBAL PERSPECTIVE 26
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