Page 54 - RP-AUGUST-2020

52 CPD ACTIVITY FROM PAGE 51 with heartburn and/or regurgitation.24 Physicians reported combination PPI and prokinetics for 45.8 per cent of cases to treat regurgitation, yet combined PPI and alginate-antacids were used by only 36.6 per cent of GPs to treat heartburn and 21.3 per cent of GPs to treat regurgitation.24 A recent study in more than 6,000 patients in the UK who had been treated with PPIs for at least two months showed that with education and access to on- demand alginate treatment, 75.1 per cent were able to taper or cease PPI therapy altogether at 12 months.27 Importantly, overall medication use was reduced, not simply swapping one medication with another. Finally, when it comes to acid suppression, it’s been long known that PPIs are superior to H2RAs, because PPIs completely inhibit three different pathways which lead to acid secretion, while H2RAs block only one.21,28,29 Given H2RAs need to be systemically absorbed, there is limited evidence for their use for rapid-relief, on-demand add-on therapy. The addition of H2RAs to PPIs has been shown to decrease nocturnal acid breakthrough,30 hence they may be more suited for night-time symptom resolution. No direct studies have compared H2RAs with alginate-based therapies.25,31 A meta- analysis which compared five studies found alginates appeared less effective than H2RAs; however, the pooled estimate was not significant.19 Based on the body of evidence, the authors suggest a new treatment pathway as outlined in Figure 1. Given the body of evidence suggests alginates are more likely to provide symptom relief than antacids,19 alginates should be recommended first before trialling acid suppression. Furthermore, as alginate therapy has been shown to successfully treat breakthrough symptoms on PPIs and assist with successful taper or cessation of PPI therapy altogether, treatments to maximise success of PPI taper is warranted. • A review of the literature shows there is additional evidence that elevates the utility of alginates above antacids in this case. • Evidence indicates that while education plus OTC treatment such as add-on alginate helps patients taper and cease PPI therapy, not all doctors routinely recommend this approach. • As alginates are available OTC, pharmacists and support staff have a key role to play in advising patients about the role of alginates in helping minimise breakthrough symptoms, with a view to tapering and ceasing their PPI. References 1. Miller G, Pan Y. Gastro-oesophageal reflux disease. In: Britt H, Miller GC, editors. General practice in Australia, health priorities and policies 1998 to 2008 General practice series no 24 Cat no GEP 24. Canberra: Australian Institute of Health and Welfare; 2009. 2. Therapeutic Guidelines. Gastrointestinal. Disorders of the oesophagus. Gastro- oesophageal reflux \\\\\\\\\\\\\\\[internet\\\\\\\\\\\\\\\]. 2019 \\\\\\\\\\\\\\\[cited 19/3/20\\\\\\\\\\\\\\\]. Available from: https://tgldcdp.tg.org.au/ viewTopic?topicfile=disorders-oesophagus&guidelin eName=Gastrointestinal#MPS_d1e815 3. Care; ACoSaQiH, Welfare; AIoHa. The Third Australian Atlas of Healthcare Variation. Sydney; 2018. 4. Nehra AK, Alexander JA, Loftus CG, Nehra V. ‘Proton pump inhibitors: Review of emerging concerns’. Mayo Clin Proc, 2018; 93 (2): 240–6. doi: 10.1016/j.mayocp.2017.10.022. 5. Xie Y, Bowe B, Yan Y, Xian H, Li T, Al-Aly Z. ‘Estimates of all cause mortality and cause specific mortality associated with proton pump inhibitors among US veterans: cohort study’. BMJV, 2019; 365: l1580. doi: 10.1136/bmj. l1580. 6. Sydney; FMRCUo. SAND abstract number 241 from the BEACH program 2015–16: proton pump inhibitor use among general practice patients \\\\\\\\\\\\\\\[Internet\\\\\\\\\\\\\\\]. 2016 \\\\\\\\\\\\\\\[cited 2020 March 19\\\\\\\\\\\\\\\]. Available from: https://sydney.edu.au/medicine/fmrc/ publications/sand-abstracts/241-PPI_use_2015.pdf 7. Australian Government. Department of Health. March 2018 PBAC outcomes - other matters \\\\\\\\\\\\\\\[Internet\\\\\\\\\\\\\\\]. 2018 \\\\\\\\\\\\\\\[cited 19/3/20\\\\\\\\\\\\\\\]. Available from: http://www.pbs.gov.au/industry/listing/elements/ pbac-meetings/pbac-outcomes/2018-03/other- matters-03-2018.pdf 8. Othman F, Card TR, Crooks CJ. ‘Proton pump inhibitor prescribing patterns in the UK: A primary care database study’. Pharmacoepidemiol Drug Saf, 2016; 25 (9): 1079–87. doi: 10.1002/pds.4043. 9. Batuwitage BT, Kingham JG, Morgan NE, Bartlett RL. ‘Inappropriate prescribing of proton pump inhibitors in primary care’. Postgrad Med J, 2007; 83 (975): 66–8. doi: 10.1136/pgmj.2006.051151. 10.Dibley LB, Norton C, Jones R. ‘Non- pharmacological intervention for gastro- oesophageal reflux disease in primary care’. Br J Gen Pract, 2010; 60 (581): e459–65. doi: 10.3399/ bjgp10X544050. 11. Carter D, Dickman R. ‘Practice styles, knowledge and attitudes of general practitioners and gastroenterology specialists who treat gastroesophageal reflux disease’. Medicine (Baltimore), 2018; 97 (52): e13781. doi: 10.1097/ MD.0000000000013781. 12.Tytgat GN, Simoneau G. ‘Clinical and laboratory studies of the antacid and raft-forming properties of Rennie alginate suspension’. Aliment Pharmacol Ther, 2006; 23 (6): 759–65. doi: 10.1111/j.1365- 2036.2006.02814.x. 13.Mandel KG, Daggy BP, Brodie DA, Jacoby HI. ‘Review article: alginate-raft formulations in the treatment of heartburn and acid reflux’. Aliment Pharmacol Ther, 2000; 14 (6): 669–90. doi: 10.1046/j.1365-2036.2000.00759.x. 14.Boeckxstaens G, El-Serag HB, Smout AJ, Kahrilas PJ. ‘Symptomatic reflux disease: the present, the past and the future’. Gut, 2014; 63 (7): 1185–93. doi: 10.1136/gutjnl-2013-306393. Figure 1. Proposed treatment pathway for OTC treatments to support patients with symptoms of GORD. 25,27 routinely offered on these occasions. Key points • The recent changes to the prescribing of PPIs on the PBS reaffirm the need to regularly review patients on prescription PPIs for GORD. • For physicians and pharmacists, knowing that symptoms cause considerable burden for patients and achieving symptom relief is important. • An update of how to integrate OTC RETAIL PHARMACY • AUG 2020 they could be