Heartburn (reflux)
Consultation guide for UK community pharmacy: clinical features, referral criteria, time frame to resolution and management strategy.
Clinical features
- Burning sensation/pain in the chest after eating (behind the sternum)
- Acid reflux into the mouth
- Bad breath
- Sore throat or coughing
- Belching
Referral criteria
- ALARM signs and symptoms which could indicate more serious causes such as carcinoma, ulceration or a GI bleed (particularly in middle or older age): Anaemia, Loss of weight, Anorexia, Recent onset of progressive symptoms and Melaena, dysphagia and haematemesis
- Pain that is severe, debilitating or that wakes the patient in the night
- Persistent vomiting
- Referred pain (always be very mindful that the symptoms could be due to a cardiac cause)
- OTC treatment failure (in line with the stipulated timeframe provided by the manufacturer)
- Consider referring children as heartburn is not common in this patient group
Time frame to resolution
- Symptoms normally are relieved immediately by the use of a combined alginate/antacid product. Proton pump inhibitors are less suitable for discrete attacks requiring immediate relief, as they take a while to reach maximal effect
- Manufacturers tend to provide their own time frame as to when medical advice should be sought; this information should form part of your safety net
Management strategy
Non-pharmacological advice
- Avoid eating meals 3-4 hours before going to bed
- Eat smaller meals more often, rather than fewer, larger meals
- Avoid triggers, such as coffee, chocolate, spicy or fatty foods (i.e. any food or drink associated with worsening or initiating symptoms)
- Wear loose fitting clothing
- To prevent reflux at night, raise the head of the bed around 10-15 cm (not just by adding more pillows, which could adversely affect the patient's neck)
- Healthy eating, weight reduction if necessary
- Smoking cessation and reduce alcohol consumption (if necessary)
- Try to relax - exercise and relaxation techniques may help
Pharmacological advice
- An OTC product containing an alginate is an appropriate first-line treatment
- Proton pump inhibitors are also effective. Products with alginates generally contain antacids, which can impair the absorption of other medicines; a proton pump inhibitor avoids the need to separate doses from other medicines. NB: OTC H2 antagonists (such as ranitidine) are no longer available in the UK following the MHRA's suspension of ranitidine licences in 2020; famotidine, cimetidine and nizatidine are prescription-only
- Proton pump inhibitors are less suitable for discrete attacks requiring immediate relief as they take a while to reach maximal effect
- Pregnancy: the first line strategy would be to discuss lifestyle measures as outlined above to see if these can resolve the symptoms without the need for pharmacological intervention, particularly in the first trimester. If the symptoms are mild and not controlled adequately by lifestyle changes, some OTC products are available and licensed for use during pregnancy, for example, Gaviscon Advance®