Occasional Reflux

    Occasional

    Success stories of Gaviscon treatment

    The patient

    Lewis is 22 years old and has recently been experiencing intermittent heartburn and regurgitation for the last 4 weeks. His symptoms occur 1–2 times a week and usually occur late in the evening whilst going to sleep. He does not experience symptoms after eating and believes that they coincide with his football training and socials after work, where he drinks alcohol.

    Two weeks ago, Lewis consulted his local pharmacist who provided him with lifestyle modification advice (which included advice on alcohol consumption). However, implementation of these changes did not relieve his symptoms and he is currently using antacids to manage them. Despite the use of antacids, Lewis is still struggling with night-time symptoms.

     

    Understanding the underlying cause(s)

    To provide Lewis with advice and treatment, it is important that his reflux trigger is determined. Several factors can trigger reflux, for example: spicy and high fat foods, alcohol and tobacco smoking.(1) In Lewis’s situation, food is unlikely to be a trigger as he does not experience symptoms after eating. However, his symptoms are likely to be caused by alcohol consumption after football training and during work socials.

    Acute alcohol consumption can relax the lower oesophageal sphincter (LOS), allowing reflux of the stomach contents into the oesophagus.(2,3) Additionally, alcohol has also been linked to gastric emptying alterations, increased acid secretion and a reduction in the LOS length.(2) Drinking before going to sleep may lead to reflux symptoms at night due to supine positioning impairing normal acid clearance from the oesophagus.(3)

     

    Consultation advice

    1. Collect a thorough history of Lewis’s symptoms and try to understand if any actions link to his reflux symptoms. For example, does he drink more alcohol on symptomatic days than others? How much alcohol does he drink? Does he have these symptoms after exercise on occasions where he does not consume alcohol?

    2. Ensure his symptoms are related to reflux and no other aetiologies.(4) For example, is it heartburn or chest pain?

    3. Identify any potential red flags. If these are present, consider referring Lewis onto a specialist.(4)

    4. Lifestyle modifications

      Before treating Lewis, you should reiterate advice on lifestyle modifications that can help manage his reflux and discuss how these can be implemented successfully.(4) For example, advise him to reduce his alcohol consumption if this is excessive.(4)

    5. Antacids

      Ask Lewis to describe how he takes his antacids. Make sure he is taking these correctly and clarify to him that long-term or continuous use is not recommended.(4) Provide him with written information and advice on antacids.(4) These should explain that antacids neutralise the gastric acid in the stomach,(1) should be taken after meals/before going to bed when needed(5) and can provide relief for ~60 minutes.(6)

    6. Alginates

      Explain to Lewis that alginates are also available for symptomatic relief and how these can be beneficial for the management of his reflux symptoms.(4) For example, unlike antacids, alginates form a raft in the stomach to physically prevent refluxate entering the oesophagus(7) and have a longer duration of action (up to 4 hours).(6,8) This helps protect the oesophagus from acid in the refluxate, in addition to other gastric factors such as bile and pepsin, which can also contribute to reflux symptoms.(7) Ensure that Lewis understands how to use alginates appropriately and provide him with written information and advice on the treatment.(4)

    7. Acid suppressing drugs

      If Lewis continues to experience symptoms, you should consider treating him with proton-pump inhibitors (PPIs).(4) PPIs irreversibly inactivate proton pumps in the stomach, suppressing both basal and stimulated acid secretion by histamine and acetylcholine.(1) Histamine 2 receptor anatagonists (H2RAs) may also be considered if there is an inadequate response to PPIs.(4) HR2As are selective, competitive antagonists that bind to histamine 2 receptors, suppressing both basal and histamine stimulated acid secretion.(1)

    If reflux symptoms persist or effective PPI treatment is not tolerated, consider testing for Helicobacter pylori.(4) Alternatively, consider referring Lewis to a specialist.(4)

    References

    1. MacFarlane B. Management of gastroesophageal reflux disease in adults: a pharmacist’s perspective. Integr Pharm Res Pract 2018;7:41–52
    2. Castillo R, Otero W, Trespalacios A. Evidence Based Review of the Impact of Treatments of Gastroesophageal Reflux Disease. Rev Col Gastroenterol 2015;30(4):431–46
    3. Chen S, Wang J, Li Y. Is alcohol consumption associated with gastroesophageal reflux disease? J Zhejiang Univ Sci B 2010;11(6):423–28
    4. NICE CKS. Dyspepsia – unidentified cause. 2018. Available: https://cks.nice.org.uk/dyspepsia-unidentified-cause#!scenarioRecommendation:1 [accessed: August 2019]
    5. NHS 2016. Antacids. Available: https://www.nhs.uk/conditions/antacids/ [accessed: October 2019]
    6. Feldman M. Comparison of the effects of over-the-counter famotidine and calcium carbonate antacid on postprandial gastric acid: a randomized controlled trial. JAMA 1996;275(18):1428–31
    7. Strugala V, Avis J, Jolliffe IG, et al. The role of an alginate suspension on pepsin and bile acids – key aggressors in the gastric refluxate. Does this have implications for the treatment of gastro-oesophageal reflux disease? J Pharm Pharmacol 2009;61:1021–28
    8. Sweis R, Kaufman E, Anggiansah A, et al. Post-prandial reflux suppression by a raft-forming alginate (Gaviscon Advance) compared to a simple antacid documented by magnetic resonance imaging and pH-impedance monitoring: mechanistic assessment in healthy volunteers and randomised, controlled, double-blind study in reflux patients. Aliment Pharmacol Ther 2013;37(11):1093–102

     

    RB-M-02499
    Date of preparation: June 2020

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