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36 GASTROESOPHAGEAL REFLUX DISEASE FROM PAGE 35 Drugs that aggravate heartburn and acid reflux Ms Rigby highlights that a range of different classes of medicines – such as calcium channel blockers used for heart conditions and high blood pressure – can cause or aggravate reflux. Other drugs that can have such effects include the bisphosphonates used for treatment and prevention of osteoporosis and non-steroidal anti- inflammatory drugs. “It doesn’t stop there,” Ms Rigby said, “because there’s so much new information coming in from studies that pharmacists need to keep abreast of, with one of the biggest issues being patients taking prescription or over-the- counter drugs for these conditions for too long a period of time.” For example, she cites the guidelines for reflux that advise people to take such medication for four to eight weeks and no longer. This highlights how important the initial diagnosis is for patients, with pharmacists and pharmacy assistants 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,1 Ms Rigby says. “Pharmacy assistants 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 and pharmacy assistants can 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 TO PAGE 38 “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.” RETAIL PHARMACY ASSISTANTS • AUG 2020