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46 HEALTH GASTRO-OESOPHAGEAL REFLUX DISEASE FROM PAGE 45 This highlights how important the initial diagnosis is for patients, with pharmacists especially called on to reinforce lifestyle interventions and determine which drugs are causing or exacerbating symptoms, Ms Rigby says. “For many people, the modus operandi of ‘set and forget’ is prevalent, with people getting onto a medication and staying on it for too long a time,” she said. Proton-pump inhibitors The discovery in 1975, that timoprazole was highly effective in reducing gastric acid secretion, was followed by the creation of a derivative, omeprazole, in 1979, which marked the advent of a new class of drugs: the proton-pump inhibitors (PPIs). Now, some 40 years later, PPIs are the most widely prescribed medications globally for patients believed to be suffering from GORD. There is a huge body of evidence now of the long-term harm that comes from taking PPIs for too long, as well as new research published in the New England Journal of Medicine finding that many people being treated for GORD aren’t, in fact, suffering from the condition,2 Ms Rigby says. “Pharmacists and patients should avoid automatically connecting heartburn to reflux disease, particularly when heartburn doesn’t vanish with PPIs,” she said. “This is because the stomach produces many substances, with anything a person consumes being available to reflux back. The causes of heartburn, too, are many and not specific to reflux disease either, making the terrain tricky.” Ms Rigby points out that PPIs have been around in Australia for about two decades, with many people taking them incorrectly and unnecessarily. Indications of the long-term harm are just beginning to emerge now, in terms of their impact on the whole microbiome in the form of deficiencies in vitamin B12 and iron, the risk of Clostridium difficile, diarrhoea and infections, and the increased risk of both community and hospital acquired pneumonia. Many people on PPIs, she adds, will present to the pharmacy with feelings of fatigue, which could be a sign of iron deficiency. “This is where a medication history would reveal if the patient has been taking PPIs year after year, which has led to an iron deficiency,” Ms Rigby said. “Then adding an iron supplement isn’t the solution, but rather going to the root of the problem. “This brings to the fore the interesting question of how to stop taking PPIs. If a patient stops abruptly, they can get rebound acid hypersecretion, where patients say all their symptoms come back, leading them to resort to PPIs again. “So, there are good guidelines that show how the dose has to be tapered, such as taking half the dose for a couple of weeks, halving that again and then stopping it.” She adds that pharmacists can also forewarn patients as to which symptoms they can expect to experience as they are weaned off PPIs. Patients can manage the symptoms by either taking some alginic acid, such as Gaviscon, or an antacid, such as Rennies, and usually after another couple of weeks any rebound symptoms will resolve, Ms Rigby says. Antacids neutralise acid. Alginates form a buffer on top of the stomach to prevent reflux up into the oesophagus. Pharmacist interactions A pharmacy dispenses a 14-day supply of medication for GORD, with directions to take the medication for the specified period, and if the symptoms don’t resolve, for the patient to return to the pharmacy or visit their GP, Ms Rigby says. “In conjunction with this, pharmacists should always look at lifestyle interventions – from avoiding food triggers or simple but effective techniques like raising the head of a bed,” she said. “These things have to be reinforced every time by the pharmacist to the patient.” Ms Rigby cautions, though, that many patients are self-diagnosing and self-treating for acid reflux and GORD because products treating these conditions are not prescription-based and available in supermarkets. Although generally safe when used at recommended doses, OTC medications can pose risks to users, including adverse drug-drug interactions, worsening of health problems, and adverse effects secondary to active ingredients, she adds. “This once again highlights the need for pharmacists to broach the topic and ensure that there are no red flags or some condition that hasn’t been properly assessed,” Ms Rigby said. “All that could be required is for the pharmacist to reassure the patient that it’s OK to take different classes of drugs, from antacids to histamine H2- receptor antagonists, commonly called H2 blockers – drugs when an antacid like calcium carbonate or aluminium hydroxide isn’t strong enough – or PPIs intermittently when they do have symptoms, which might be for a special occasion dinner with some alcohol.” This follows concern with H2 blockers. Drug makers recently recalled the H2 blocker ranitidine after the cancer-causing chemical N-nitrosodimethylamine was found in several brand-name and generic versions of the medication. Generally, though, Ms Rigby assures that H2 blockers are safe to use, with the biggest issue being that they don’t always suppress acid and may become less effective as the body habituates to them. Another red flag is that of patients not achieving relief through PPIs because they are not taking their medicines half an hour to an hour before meals. The reason for this is that PPIs hinder acid from making cells in the stomach, meaning that the cells must be making acid when the medication is in the bloodstream. Also important, Ms Rigby says, is that the patient is on the lowest effective dose when it comes to OTC PPIs. “Patients often get onto the highest dose and remain there, making a trial period to determine the correct dose crucial,” she said. “If a patient has to be on PPIs long term, they should have a trial to reduce their dose by stepping down to intermittent therapy if they’re only getting the symptoms every now and then.” Mark Webster, owner of Stay Well Pharmacy in Christchurch, New Zealand, says in his experience most patients don’t know whether they’re suffering from GORD, reflux or heartburn. “Even getting patients to adequately describe their symptoms is difficult, such as whether their symptoms are experienced in their stomach, before or after a meal, or at night, etc,” he said. “I ask them: do you wake up with an RETAIL PHARMACY • AUG 2020