Pharmacist Approach to Heartburn, continued. consider discontinuing therapy. When stopping a PPI in someone who has been on therapy for several months, some symptomatic rebound acid secretion is a possibility. This could be misinterpreted as a need for ongoing therapy. It is reasonable to taper the PPI over time although evidence is lacking regarding an optimal tapering process. In general, when tapering one may either: a) decrease the PPI dose by 50% for a few weeks or, b) increase the interval between doses to every 2 or more days. This approach may be preferred for PPIs if the lower dose formulation is, relatively, more costly. Antacids or an H2RA such as ranitidine may be used during the taper. In most patients taking long-term PPI therapy for uncomplicated, symptomatic GERD, it is reasonable to attempt to stop or reduce the dose of the PPI at least once per year. Two main concerns with OTC PPI and other therapies are the possibility of misdiagnosis or the under-treatment of patients with severe GERD who require supervised medical care rather than OTC therapy, hence the significance of a 2 week trial period.10 Omeprazole may interact with other medications that depend on hepatic CYP 2C19 for metabolism; in particular, it can delay the clearance of diazepam, phenytoin, and warfarin. Because PPIs cause such a profound inhibition of gastric acid secretion, they may interfere with the absorption of drugs for which gastric pH is an important determinant of bioavailability (e.g., ketoconazole, digoxin).11 There has been some concern with the concomitant use of clopidogrel and medications that are CYP-2C19 inhibitors. Douglas et.al.12 report that the interaction between clopidogrel and PPIs is clinically unimportant. Clinicians may prefer Ranitidine and Pantoprazole. There have been reports of hypomagnesaemia with some long term users of PPIs. Patients experiencing muscle cramps, palpitations, tremor, and/or dizziness may have their magnesium levels checked.13 It will always be important to assess the benefit of the chosen therapy (Figure 10). Figure 8 Potential consequences of long-term use of proton pump inhibitors 9 Figure 10 Patient benefit assessment Heartburn and GERD 1 Herbal Remedies: There isn’t much research into herbal products for heartburn. While there is some evidence for the benefit of a few natural products14 (e.g., Angelica, Artichoke, Caraway, German Chamomile and Lemon Balm) for dyspepsia, there is no, or limited, evidence for natural products to treat heartburn. Bitter Orange, Capsicum, Fenugreek and Turmeric for example have no convincing evidence. Just because herbal remedies may be seen as ‘natural’, they can still interfere with other medicines. Can drinking milk or chewing gum help heartburn? While milk may temporarily buffer stomach acid, nutrients in milk, particularly fat, will stimulate the stomach to produce more acid. Overfilling the stomach may increase heartburn. It may sound strange but gum stimulates the production of saliva, which is an acid buffer. Peppermint free chewing gum also makes you swallow more often, which could improve the clearance rate of reflux within the esophagus.15 It has been suggested that yogurt and papaya or papaya juice may reduce heartburn. In summary, pharmacists with access to evidence based treatment guidelines, an understanding of heartburn and related illnesses, and an understanding of available medicines can assist any patient in the caring for their heartburn. Figure 9 Advice to patient for Heartburn and GERD 1 World Digestive Health Day WDHD May 29, 2015 WGO HANDBOOK HEARTBURN: A GLOBAL PERSPECTIVE 28
WDHD-2015-handbook-final
To see the actual publication please follow the link above