Indigestion
Consultation guide for UK community pharmacy: clinical features, referral criteria, time frame to resolution and management strategy.
Clinical features
- Often associated with eating/drinking
- Feeling of fullness
- Nausea
- Belching
- Upper abdominal discomfort or pain which may be described as a heaviness/ache
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 indigestion is not common in this patient group
Time frame to resolution
- Mild to moderate symptoms of indigestion will experience immediate relief from a liquid antacid formulation but further doses may be needed if symptoms return. If the indigestion is a one-off episode due to food/alcohol, the symptoms should resolve in a day or so
- OTC manufacturers of proton pump inhibitors will stipulate the timeframe for which the product should be taken and also when to stop using if symptoms have not resolved
Management strategy
Non-pharmacological advice
- Healthy eating, weight reduction if necessary, and exercise
- Smoking cessation and reduce alcohol consumption (if necessary)
- Avoid triggers, such as spicy or fatty foods or large quantities of food
Pharmacological advice
- Recommend antacids for mild dyspeptic symptoms (i.e. not associated with heartburn). Check product licence (or marketing authorisation) of the product prior to sale to ensure it is not solely licensed for reflux or reflux-related conditions, rather than the more generic terms such as 'dyspepsia' or 'indigestion'
- Liquid antacids work faster and have a greater neutralising capacity than solid dosage forms. Using antacids after eating increases residence time in the stomach and should give longer relief than using prior to meals
- Antacids can impair the absorption of other medicines and can damage enteric coatings. Leave an appropriate gap between antacids and other medicines - see manufacturer's advice, BNF or Stockley's Drug Interactions for details
- Where patient compliance is a concern (for example, to minimise interactions between antacids and other medicines), note that OTC omeprazole and esomeprazole products such as Pyrocalm Control and Nexium Control are licensed for the short-term treatment of reflux symptoms (heartburn, acid regurgitation) in adults — check the licence before suggesting one for dyspepsia without reflux, and refer if an antacid is unsuitable. Note: OTC pantoprazole (Pantoloc Control) has been discontinued and is no longer available. Note: OTC H2 antagonists (such as ranitidine) are no longer available in the UK following the MHRA's suspension of ranitidine licences in 2020
- Advise that frequent, long-term continuous use of antacids is not appropriate and can result in morbidity
- 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 - check individual products prior to sale