OTCs Today
Daniel L. Krinsky, RPh, MS
This time of year, with all the less-than-healthy eating opportunities, heartburn and dyspepsia (indigestion) will be more prevalent—as will opportunities to help our patients.
Heartburn is characterized by a burning sensation in the stomach or lower chest which usually occurs after meals. Dyspepsia is characterized by discomfort in the upper abdomen, postprandial fullness, early satiation, epigastric pain, or epigastric burning.
A number of risk factors are associated with the occurrence of heartburn. These include certain foods (e.g., fat, chocolate, peppermint, citrus, tomato-based, and spicy foods), caffeine, carbonated beverages, alcohol, tobacco, and certain medications (e.g., theophylline, morphine, calcium channel blockers, diazepam). Other factors include lifting heavy objects, performing isometric exercises, obesity, and genetics.
Nonpharmacologic options that can be recommended for symptom management include avoiding triggers, avoiding eating large meals, stopping smoking, losing weight, avoiding lying down within 3 hours of a meal, elevating the head of the bed if experiencing nocturnal symptoms.
Various categories of nonprescription medications are available to manage heartburn. Antacids can be used at the onset of symptoms; relief typically begins within 5 minutes. Generally, they should not be used more than 4 times a day or regularly for more than 2 weeks. Key adverse effects include diarrhea with magnesium- or magnesium/aluminum–containing antacids, and constipation with aluminum- or calcium-containing antacids. Importantly, avoid any salicylate-containing products in those under 18 years.
Histamine-2 receptor antagonists (H2RAs) are usually taken at the onset of symptoms or 30 minutes to 1 hour before symptoms are expected. Symptom relief starts within 30 to 45 minutes after the medication is taken. These are usually taken “as needed” when a longer duration of effect is desired versus antacids, up to twice daily for 2 weeks. If symptoms are not relieved with recommended doses, worsen, or persist after 2 weeks of treatment, the patient should consult their primary care provider. Adverse effects are infrequent; those reported include headache, dizziness, diarrhea, and constipation. Currently there are 2 options: famotidine and cimetidine, with famotidine being the safest of the 2 options as it has fewer potential adverse effects and drug interactions.
Proton pump inhibitors (PPIs) are indicated for mild-to-moderate, frequent heartburn that occurs 2 or more days a week. Importantly, they are not intended for the relief of mild, occasional heartburn. The typical dose is once daily with a glass of water every morning 30 minutes before breakfast. Patients should see an initial response within the first few days, and complete resolution of symptoms within 4 days of initiating treatment. If symptoms persist, worsen, are not adequately relieved after 2 weeks of treatment, or recur before 4 months has elapsed since treatment, the patient should consult their primary care provider. Adverse effects are infrequent; those reported include dizziness, headache, abdominal pain, rash, diarrhea, nausea, vomiting, and constipation. When recommending a PPI, be sure to obtain a medication history as there is potential overlap with prescription PPIs, and there are potential drug interactions with warfarin, clopidogrel, cilostazol, ketoconazole, phenytoin, diazepam, antiretroviral medications, methotrexate, theophylline, tacrolimus, and digoxin. With any of the above classes of medications, adverse effects should resolve in a few days; if the problem does not resolve or gets worse, the patient should consult their primary care provider.
Encourage your patients to enjoy the holidays, but if a mild gastrointestinal condition arises, they should consult with you for management options.