Abstract
Heartburn and acid regurgitation are the classic symptoms of gastroesophageal reflux disease (GERD). Heartburn is defined as a burning sensation in the retrosternal area (behind the breastbone) and regurgitation is the perception of flow of refluxed gastric content into the mouth or hypopharynx. GERD is the most prevalent acid-related disorder in Canada and affects 10–30% of the population in the United States and Europe. Assessment of the patient with heartburn requires knowledge of characteristic, atypical, and nonspecific symptoms, as well as the red flags that may indicate a more sinister underlying cause (e.g., gastric carcinoma) and require referral to a physician for further workup. It is important to determine if the patients’ heartburn symptoms could be caused by an underlying medical condition that, in some cases, could be life-threatening (e.g., cardiac chest pain). Patients presenting to the community pharmacist with classic heartburn or regurgitation in the absence of red flags can confidently self-treat their symptoms with various over-the-counter (OTC) acid-lowering products, including proton pump inhibitors (PPI), without requirement for further referral or investigation. Patients should be advised to follow-up with their pharmacist or physician if their symptoms persist after a 2–4-week trial of OTC therapy. Patients presenting with new epigastric pain as their predominant symptom (i.e., undiagnosed dyspepsia) should be referred to their physician for further assessment. Therapy for GERD is typically limited to 4–8 weeks, but chronic use of PPI therapy is common. In these situations, it is important to assess the patient history, as there are several indications where continued long-term PPI therapy is appropriate (e.g., Barrett’s esophagus, chronic NSAID users with bleeding risk, severe esophagitis, and documented history of bleeding ulcers). In the absence of these indications, lowering the dose or stopping PPI therapy may be appropriate.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108:308–28; quiz 29.
Holtmann G, Bigard MA, Malfertheiner P, Pounder R. Guidance on the use of over-the-counter proton pump inhibitors for the treatment of GERD. Int J Clin Pharm. 2011;33:493–500.
Boardman HF, Heeley G. The role of the pharmacist in the selection and use of over-the-counter proton-pump inhibitors. Int J Clin Pharm. 2015;37:709–16.
Boardman HF, Delaney BC, Haag S. Partnership in optimizing management of reflux symptoms: a treatment algorithm for over-the-counter proton-pump inhibitors. Curr Med Res Opin. 2015;31:1309–18.
Armstrong D, Nakhla N. Non-prescription proton-pump inhibitors for self-treating frequent heartburn: the role of the Canadian pharmacist. Pharm Pract (Granada). 2016;14:868.
Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R, Global Consensus Group. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol. 2006;101:1900–20; quiz 43.
Richter JE. Typical and atypical presentations of gastroesophageal reflux disease. The role of esophageal testing in diagnosis and management. Gastroenterol Clin North Am. 1996;25:75–102.
Hunt R, Armstrong D, Katelaris P, Afihene M, Bane A, Bhatia S, et al. World gastroenterology organisation global guidelines: GERD global perspective on gastroesophageal reflux disease. J Clin Gastroenterol. 2017;51:467–78.
Moayyedi PM, Lacy BE, Andrews CN, Enns RA, Howden CW, Vakil N. ACG and CAG clinical guideline: management of dyspepsia. Am J Gastroenterol. 2017;112:988–1013.
Vakil N, Halling K, Ohlsson L, Wernersson B. Symptom overlap between postprandial distress and epigastric pain syndromes of the Rome III dyspepsia classification. Am J Gastroenterol. 2013;108:767–74.
van Zanten SV, Armstrong D, Barkun A, Junghard O, White RJ, Wiklund IK. Symptom overlap in patients with upper gastrointestinal complaints in the Canadian confirmatory acid suppression test (CAST) study: further psychometric validation of the reflux disease questionnaire. Aliment Pharmacol Ther. 2007;25:1087–97.
Talley NJ, Vakil NB, Moayyedi P. American gastroenterological association technical review on the evaluation of dyspepsia. Gastroenterology. 2005;129:1756–80.
Haag S, Andrews JM, Katelaris PH, Gapasin J, Galmiche JP, Hunt R, et al. Management of reflux symptoms with over-the-counter proton pump inhibitors: issues and proposed guidelines. Digestion. 2009;80:226–34.
Talley NJ, Vakil N, Practice Parameters Committee of the American College of Group. Guidelines for the management of dyspepsia. Am J Gastroenterol. 2005;100:2324–37.
El-Serag HB, Sweet S, Winchester CC, Dent J. Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut. 2014;63:871–80.
Armstrong D, Marshall JK, Chiba N, Enns R, Fallone CA, Fass R, et al. Canadian consensus conference on the management of gastroesophageal reflux disease in adults – update 2004. Can J Gastroenterol. 2005;19:15–35.
Tougas G, Chen Y, Hwang P, Liu MM, Eggleston A. Prevalence and impact of upper gastrointestinal symptoms in the Canadian population: findings from the DIGEST study. Domestic/International Gastroenterology Surveillance Study. Am J Gastroenterol. 1999;94:2845–54.
Camilleri M, Dubois D, Coulie B, Jones M, Kahrilas PJ, Rentz AM, et al. Prevalence and socioeconomic impact of upper gastrointestinal disorders in the United States: results of the US Upper Gastrointestinal Study. Clin Gastroenterol Hepatol. 2005;3:543–52.
Boeckxstaens G, El-Serag HB, Smout AJ, Kahrilas PJ. Symptomatic reflux disease: the present, the past and the future. Gut. 2014;63:1185–93.
Zografos GN, Georgiadou D, Thomas D, Kaltsas G, Digalakis M. Drug-induced esophagitis. Dis Esophagus. 2009;22:633–7.
Tutuian R, Clinical Lead Outpatient Services, Gastrointestinal Function Laboratory. Adverse effects of drugs on the esophagus. Best Pract Res Clin Gastroenterol. 2010;24:91–7.
Kahrilas P, Hirano I. Chapter 347. Diseases of the esophagus. In: Kahrilas P, Hirano I, editors. Harrison’s principles of internal medicine. 19th ed. New York: McGraw Hill; 2015.
Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. Clinical Guideline [CG184]. 2014. https://www.nice.org.uk/guidance/cg184. Accessed 15 May 2018.
Hunt R, Quigley E, Abbas Z, Eliakim A, Emmanuel A, Goh KL, et al. Coping with common gastrointestinal symptoms in the community: a global perspective on heartburn, constipation, bloating, and abdominal pain/discomfort May 2013. J Clin Gastroenterol. 2014;48:567–78.
GERD – Treatment Flowchart. https://medsask.usask.ca/professional/guidelines/gerd.php. Accessed 12 Mar 2018
GERD – Pharmacist Assessment Document. https://medsask.usask.ca/professional/guidelines/gerd.php. Accessed 12 Mar 2018.
Johnson DA, Katz PO, Armstrong D, Cohen H, Delaney BC, Howden CW, et al. The safety of appropriate use of over-the-counter proton pump inhibitors: an evidence-based review and Delphi consensus. Drugs. 2017;77:547–61.
Simonson W. Implications of over-the-counter proton pump inhibitors for patient counseling by pharmacists. Am J Ther. 2013;20:676–84.
Tytgat GN, McColl K, Tack J, Holtmann G, Hunt RH, Malfertheiner P, et al. New algorithm for the treatment of gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2008;27:249–56.
Armstrong D, Marchetti N. Pharmacist-specific guidelines for the medical management of GERD in adults. Can Pharm J. 2008;141(Suppl 1):S10–S5.
Kaltenbach T, Crockett S, Gerson LB. Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach. Arch Intern Med. 2006;166:965–71.
Sigterman KE, van Pinxteren B, Bonis PA, Lau J, Numans ME. Short-term treatment with proton pump inhibitors, H2-receptor antagonists and prokinetics for gastro-oesophageal reflux disease-like symptoms and endoscopy negative reflux disease. Cochrane Database Syst Rev. 2013;5:CD002095. https://doi.org/10.1002/14651858.CD002095.pub5.
OLEX Product Monograph. 2014. http://olex24.ca/public/default/pdfs/olex-product-monograph.pdf. Accessed 29 May 2018.
Nexium 24Hr Product Monograph. 2017. https://www.pfizer.ca/sites/g/files/g10047126/f/201804/HCApproved_PM_Nexium%2024HR_CN207640_EN_20Sep2017.pdf. Accessed 29 May 2018.
Klauser AG, Schindlbeck NE, Muller-Lissner SA. Symptoms in gastro-oesophageal reflux disease. Lancet. 1990;335:205–8.
Moayyedi P, Talley NJ, Fennerty MB, Vakil N. Can the clinical history distinguish between organic and functional dyspepsia? JAMA. 2006;295:1566–76.
Bytzer P, Jones R, Vakil N, Junghard O, Lind T, Wernersson B, et al. Limited ability of the proton-pump inhibitor test to identify patients with gastroesophageal reflux disease. Clin Gastroenterol Hepatol. 2012;10:1360–6.
Numans ME, Lau J, de Wit NJ, Bonis PA. Short-term treatment with proton-pump inhibitors as a test for gastroesophageal reflux disease: a meta-analysis of diagnostic test characteristics. Ann Intern Med. 2004;140:518–27.
Schaffer E. Gastroesophageal reflux disease. In: Compendium of therapeutic choices. Ottawa, Ontario: Canadian Pharmacists Association; 2017.
Wedemeyer RS, Blume H. Pharmacokinetic drug interaction profiles of proton pump inhibitors: an update. Drug Saf. 2014;37:201–11.
Focks JJ, Brouwer MA, van Oijen MG, Lanas A, Bhatt DL, Verheugt FW. Concomitant use of clopidogrel and proton pump inhibitors: impact on platelet function and clinical outcome- a systematic review. Heart. 2013;99:520–7.
Ogawa R, Echizen H. Clinically significant drug interactions with antacids: an update. Drugs. 2011;71:1839–64.
Vazquez JC. Heartburn in pregnancy. BMJ Clin Evid. 2015;2015:1411.
Marrero JM, Goggin PM, de Caestecker JS, Pearce JM, Maxwell JD. Determinants of pregnancy heartburn. Br J Obstet Gynaecol. 1992;99:731–4.
Veldhuyzen van Zanten SJ, Bradette M, Chiba N, Armstrong D, Barkun A, Flook N, et al. Evidence-based recommendations for short- and long-term management of uninvestigated dyspepsia in primary care: an update of the Canadian dyspepsia working group (CanDys) clinical management tool. Can J Gastroenterol. 2005;19:285–303.
Richter JE. Review article: the management of heartburn in pregnancy. Aliment Pharmacol Ther. 2005;22:749–57.
Phupong V, Hanprasertpong T. Interventions for heartburn in pregnancy. Cochrane Database Syst Rev. 2015;9:CD011379. https://doi.org/10.1002/14651858.CD011379.pub2.
Richter JE. Gastroesophageal reflux disease during pregnancy. Gastroenterol Clin N Am. 2003;32:235–61.
Hofmeyr GJ, Lawrie TA, Atallah AN, Duley L, Torloni MR. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Syst Rev. 2014:CD001059.
Tytgat GN, Heading RC, Muller-Lissner S, Kamm MA, Scholmerich J, Berstad A, et al. Contemporary understanding and management of reflux and constipation in the general population and pregnancy: a consensus meeting. Aliment Pharmacol Ther. 2003;18:291–301.
Majithia R, Johnson DA. Are proton pump inhibitors safe during pregnancy and lactation? Evidence to date. Drugs. 2012;72:171–9.
Farrell B, Pottie K, Thompson W, Boghossian T, Pizzola L, Rashid FJ, et al. Deprescribing proton pump inhibitors: evidence-based clinical practice guideline. Can Fam Physician. 2017;63:354–64.
Boghossian TA, Rashid FJ, Thompson W, Welch V, Moayyedi P, Rojas-Fernandez C, et al. Deprescribing versus continuation of chronic proton pump inhibitor use in adults. Cochrane Database Syst Rev. 2017;(3):CD011969.
Bye Bye PPI: A toolkit for deprescribing proton pump inhibitors in EMR-enabled primary care settings. https://choosingwiselycanada.org/wp-content/uploads/2017/07/CWC_PPI_Toolkit_v1.2_2017-07-12.pdf. Accessed 31 May 2018.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2019 Springer Nature Switzerland AG
About this chapter
Cite this chapter
Makowsky, M. (2019). Heartburn. In: Mahmoud, S. (eds) Patient Assessment in Clinical Pharmacy. Springer, Cham. https://doi.org/10.1007/978-3-030-11775-7_9
Download citation
DOI: https://doi.org/10.1007/978-3-030-11775-7_9
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-030-11774-0
Online ISBN: 978-3-030-11775-7
eBook Packages: MedicineMedicine (R0)