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38 GASTROESOPHAGEAL REFLUX DISEASE “Pharmacists should always look at lifestyle interventions – from avoiding food triggers or simple but effective techniques like raising the head of a bed.” FROM PAGE 36 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 and their assistants 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 pharmacy 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. RETAIL PHARMACY ASSISTANTS • AUG 2020