People commonly come into the pharmacy to ask for advice on heartburn or reflux. The most frequently prescribed medications in Australia are for reflux. In general, most people will attempt to self-treat their reflux or heartburn symptoms. However, receiving proper advice on medications and lifestyle measures can be of great value in treating reflux and preventing complications and sometimes drug interactions.
GORD
What are the symptoms of heartburn, indigestion and Gastro-Oesophageal Reflux Disease (GORD)?
Reflux is a normal process which occurs when stomach acid frequently flows back into the tube, connecting your mouth and stomach (Oesophagus). This backwash (acid reflux) can irritate the lining of your Oesophagus. Many people experience acid reflux from time to time.
These symptoms occur; however, their severity and frequency can vary depending on diet and lifestyle factors. When the symptoms occur two or more times a week, become troublesome, or complications arise, then it is classified as a disease known as Gastro-Oesophageal Reflux Disease (GORD).
Heartburn
Heartburn is not always GORD. Heartburn is the burning sensation from the stomach or behind the breastbone, rising up towards the throat. Heartburn can also include an unpleasant taste in the mouth and uncommonly chest pain. Other symptoms include over salivation and nausea. However, heartburn can be part of GORD but does not define the disease.
Regurgitation is the rising of the stomach contents into the mouth or throat. If reflux symptoms are severe enough to affect the quality of life, then the patient is considered to have GORD.
Indigestion
Indigestion often called dyspepsia, is the term used to describe the symptoms of pain, burning or discomfort in the upper abdomen. Other symptoms include feeling full soon after eating, belching, bloating, flatulence, heartburn, nausea and vomiting. Indigestion is mostly linked to eating or drinking but may be associated with other diseases.
The Sphincter and GORD
The tube linking the stomach and the mouth known as the Oesophagus, is connected by a ring of muscles known as the sphincter. If the sphincter is working properly, it prevents food from moving back up from the stomach to the Oesophagus. When the sphincter loses tone or weakens, food passes back more easily from the stomach to the Oesophagus, causing that heartburn feeling. The loss in tone or weakness in the sphincter is known as Gastro-Oesophageal Reflux Disease (GORD).
Who is at risk of getting Heartburn and Indigestion?
Risk factors for reflux symptoms such as heartburn include obesity, increased age, male gender, poor diet, excessive alcohol/caffeine intake, smoking, stress and genetics.1,4
Heartburn may be caused by indigestion, stress/anxiety, delayed gastric emptying, GORD, Helicobacter pylori infection, peptic ulcer disease and gall bladder disease.
Indigestion can be triggered by diet and lifestyle factors such as overeating, eating too quickly, and eating spicy, rich or fatty foods. Caffeine and alcohol are both known to precipitate indigestion; sugary or carbonated beverages can also cause symptoms.
Heartburn can also be the result of a hiatal hernia. A hiatal hernia happens when part of the stomach pushes through the diaphragm and into the chest.
Heartburn is also a common condition during pregnancy. When a woman is pregnant, the progesterone hormone can cause the lower oesophageal sphincter to relax. This allows stomach contents to travel into the Oesophagus, causing irritation.
Lifestyle and GORD
Health conditions or lifestyle choices which can worsen your heartburn, include:
- Smoking
- Increased age
- Males
- Poor diet
- Stress/Anxiety
- Genetics
- Being overweight or obese
- Consuming caffeine, chocolate, or alcohol
- Eating spicy foods
- Lying down immediately after eating
- Medications (See below)
- Other diseases such as GORD, Helicobacter pylori infection, peptic ulcer disease and gall bladder disease.
Medicines that can cause heartburn and indigestion
Medications can play a role in heartburn or indigestion in several ways.
Some medications can irritate the Oesophagus (tube linking stomach to mouth), these include:
- Aspirin
- Non-Steriondal anti-inflammatories such over the counter Voltaren and Nurofen
- Drugs used for Osteoporosis known as Bisphonsphonates (e.g. Actonel and Fosamax)
- Iron and Potassium Supplements
- Antibiotic known as tetracycline
Other Medications can delay the presence of food in the stomach by delaying the process of digestion. These medications increase the chance of food being pushed back up into the Oesophagus, causing that heartburn feeling. These group of drugs include:
- Glucagon-like peptide-1 analogues (e.g. Trulicity, Byetta, Saxenda)
- Anticholinergic Medications (Ditropan and other very long list of medications)
- Opioids (Morphine-like medications)
Another group of drugs can also contribute to reflux by relaxing the sphincter. These include:
- Alpha Blockers (e.g. Prozasin)
- Anticholinergic Medications (e.g. Endep)
- Benzodiazepines (e.g. Valium and similar medications)
- Calcium Channel Blockers (e.g. Amlodipine and Nifedipine)
- Oral and Inhaled Corticosteroids (e.g. Prednisolone, Seretide, Symbicort)
- Dopaminergic Agents (e.g. Sinemet)
- Nitrates (e.g. Duride and Imdur)
- Phosphodiesterase-5 Inhibitors (e.g. Viagra and Cialis)
- Progesterone
- Theophylline
Complications of Heartburn and Indigestion
Complications arising from unmanaged heartburn can be serious.
Prolonged exposure of acid to the Oesophagus from the stomach can lead to scarring in the Oesophagus. These scars can cause narrowing of the Oesophagus leading to difficulty of swallowing. Surgery may be required to dilate the Oesophagus.
The continued exposure of acid in the Oesophagus can also burn the cells causing bleeding known as Peptic Ulcer and Barrett’s Oesophagus.
Other complications of continued acid exposure include cellular changes leading to some forms of cancer.
Hence, often getting the correct advice is not just about treating your current issue but preventing that preventable disease.
What self-care options can relieve symptoms of heartburn and indigestion?
The main treatment goals for heartburn are relief of symptoms and improvement in the quality of life. However, suppose heartburn has been unmanaged for a significant period. In that case, the purposes of treatment also include healing the Oesophagus and reducing the risk of long-term complications.
Lifestyle changes, such as reducing alcohol intake and smoking cessation, can help relieve symptoms. Weight loss in overweight patients or raising the bed head (if symptoms occur at bedtime) can also be beneficial.
Dietary modifications such as avoiding trigger foods (e.g. chocolate, caffeine, fatty or spicy foods), eating smaller meals, and not eating close to bedtime can all help reduce reflux symptoms such as heartburn.
Current Treatment for GORD
If diet and lifestyle modifications are insufficient to manage symptoms, then medications can be used when necessary.
Antacids can be used on an ‘as required’ basis to manage mild, intermittent symptoms. However, antacids tend to have a short duration of effect, so are best reserved for those with intermittent symptoms.
A step up approach can be used from weakest to strongest.
- Antacids (such as Mylanta and Gaviscon)
- Alginates (Gaviscon Dual Action)
- Prescription Medications
Complications of GORD medications
It is strongly recommended to always to check with your doctor how long you should take a medication for GORD. Many of the prescription medications may have long term complications. These complications are predictable as the acid in our stomach is there for a reason. Studies have shown that the long-term of some prescription medications for GORD can lead to gut infections, pneumonia and kidney disease. Depletion of magnesium levels, reduced bone mineral density and fracture, and reduced vitamin B12 levels can also occur.
Compounding, Reflux and Children
Children often suffer from GORD too. They may be more challenging to treat, as it is obviously difficult to know the source of their discomfort. Reflux is presented as spitting up, posseting or bringing milk up, and is common in babies, especially after a feed.
How is reflux diagnosed in babies?
A doctor diagnoses reflux. GORD requires a doctor’s assessment and tests to confirm a diagnosis.
Sometimes there may be another problem that causes reflux. You should see your GP if your baby has any of the following symptoms:
- Green, yellow or blood-stained vomiting
- Difficulty swallowing is gagging or choking
- Fever
- Irritability and consistently challenging to settle
- Sudden and forceful vomiting in large volumes
- Refusing feeds or won’t eat
- Swollen or bloated tummy area
- Blood or mucous in poo
- Losing weight or only gaining weight slowly.
Treatment in Babies
It is often tricky to dose babies. A compounding pharmacist can design a tailored dose to suit your baby. The strength, volume and flavour can be tailor-made. Often doctors and paediatricians will prescribe a compounding prescription for reflux. Contact us for further details or enquiries.