Eating food is meant to be a pleasurable experience. However, post-meal, some of us may encounter unpleasant symptoms of gastro-oesophageal reflux disease (GORD). Many of us will experience acid reflux from time to time; however, GORD is when reflux occurs more than twice a week.
The signs include heartburn, acid regurgitation into the throat and difficulty swallowing.
Reflux can strike when stomach acid rises into the food pipe (oesophagus) and sometimes the throat. A band of muscle, the sphincter at the top of the stomach, normally lets food into the stomach while also stopping food acid from going back up the oesophagus. However, when the (sphincter) at the top weakens, it doesn’t close properly, enabling stomach acid to go up.
While it’s not a pleasant experience after having just finished a delicious meal, it can also be very disruptive and affect quality of life, especially if it is in the more severe form. The condition must be managed well and as early as possible.
Symptoms
Heartburn is one of the main symptoms of GORD, which feels like burning pain in the chest and feels worse after eating heavy meals or lying down.
Other uncomfortable symptoms of GORD include chest pain, wheezing, a persistent cough, painful swallowing due to ulcers in the oesophagus, vomiting, burping, bloating, bad breath and tooth decay.
Complications of untreated or poorly treated GORD
The complications that can occur if GORD is not managed or treated include scarring and narrowing of the oesophagus, which can affect the ability to swallow, ulcers and, in a minority of cases, an increased risk of cancer.
Other GORD-related issues include tooth decay, chronic coughs, sinusitis, and vocal cord inflammation.
Causes of GORD
Most causes of GORD are related to a weakening of the lower oesophageal sphincter. Although the exact reason for this is unknown, it’s more likely to happen in people with higher pressure in the abdomen (belly), such as those who are overweight or pregnant.
Pregnancy and the associated changes in hormone levels and pressures in the stomach mean these women have a higher chance of having GORD.
People with a hiatus hernia, where part of the stomach slides up through the diaphragm into the chest, may also have a higher risk of GORD.
Those who suffer from stress or take certain inflammatory medications such as ibuprofen may also have a higher risk of GORD.
Other medical conditions that affect the lower oesophageal sphincter and may have an increased risk of GORD include diabetes and some connective tissue diseases.
Large meals and certain foods can trigger symptoms of GORD, as this makes the stomach expand, making reflux more likely. These include caffeine, alcohol, spicy foods, fatty foods, and tomatoes.
Treatment
Treatment for reflux depends on the severity and frequency of symptoms or if there are any complications. Most people will experience temporary reflux symptoms in their life.
- Lifestyle
Accredited Practicing Dietitian (APD) Jacinta Sherlock recommends the following changes:
- Small meals and snacks to limit the volume of food in the gut.
- Ensure ample time between the last eating episode and sleep to allow for adequate digestion.
- Limit highly processed foods, limit foods high in fat, and limit carbonated beverages, caffeine, and alcohol.
- Avoid tomatoes, citrus fruits, and fruit juices.
- Avoid known triggers, which may be gluten and dairy for some people.
- Routine elimination of foods isn’t recommended.
If people are making changes to their diet, it is recommended to consult an APD to ensure nutritional adequacy and prevent any nutrient deficiencies.
Elevating the head of the bed may be helpful to reduce reflux. Tobacco smoke and alcohol irritate the digestive system, so reducing these habits may assist with alleviating symptoms.
Being overweight can contribute to reflux and losing weight as according to a paper published by the Australian Prescriber, this has the strongest evidence for efficacy.
- Over the counter
If diet and lifestyle changes alone cannot sufficiently control mild intermittent gastro-oesophageal reflux symptoms, then over-the-counter antacids or H2 receptor antagonists are available to try.
- Proton pump inhibitors
If these do not provide adequate relief, then a visit to the GP may be helpful to assess whether the symptoms are of GORD, after which the doctor may prescribe drugs called proton pump inhibitors (PPI), which reduce the amount of acid the stomach makes.
Treatment should be combined with recommended lifestyle changes, particularly weight loss.
Ms Sherlock explained: “Over-the-counter treatments may aid in the short-term management of symptoms. However, research advises against the long-term use of over-the-counter treatments, as they don’t address the underlying dysfunction in the gut. The body naturally wants to return to homeostasis, and we want to identify why this isn’t occurring. Looking towards lifestyle changes, what I would term medicinal living, also known as natural solutions over pharmaceutical interventions, would be the first line of recommendations in both short-term and long-term management.”
Surgery is only required in a small percentage of cases. Dr George Babalis, a bariatric (weight loss) and upper gastrointestinal surgeon, said: “Acid reflux surgery is beneficial if patients do not respond to medication, experience side effects from anti-acid medications, or prefer to undergo surgery than take medication on a lifelong basis.”
Prevention
Ms Sherlock explains that as reflux occurs in response to ineffective relaxation of the lower oesophageal sphincter, dietary solutions alone are unlikely to prevent reflux. However, they can be used to help reduce the symptoms someone is experiencing.
Role of pharmacists
If a patient’s reflux presents with weight loss, difficulty or pain in swallowing, or vomiting of blood, a referral to a healthcare provider will be necessary, as The Royal Australian College of General Practitioners (RACGP) reports that these symptoms require further and immediate investigation. This may involve a doctor’s examination of the inside of the oesophagus and stomach through a ‘gastroscopy’ or ‘endoscopy’ to help determine the appropriate treatment.
- Appropriate use of PPIs
Dr Jill Thistlethwaite, Medical Advisor, NPS MedicineWise, has said: “As PPIs are prescribed frequently and are effective at reducing symptoms, some people may consider them as lifetime medicines. However, long-term regular PPI therapy is generally not necessary nor recommended for most people with GORD.”
This was also discussed in a paper published in the Gastroenterology Report, which states there is widespread overprescribing of PPIs in Western and Eastern nations.
The Australian Journal of General Practice reports that PPIs are generally well tolerated; however, use beyond eight weeks is rarely indicated and increases the risk of adverse events.
Dr Thistlethwaite said: “After completing an initial course of daily PPI treatment, which is usually around four to eight weeks, many people can reduce and step down the amount of medicine they take and still maintain control of their symptoms. Up to six out of 10 people can also step down and stop taking PPIs without their symptoms returning.”
However, she says it’s important that patients have a conversation with their doctor before stopping treatment to ensure this is done safely and effectively.
Choosing Wisely Australia has recommendations from the RACGP and the Gastroenterological Society of Australia (GESA) on the appropriate use of PPIs in clinical practice. One of these recommendations is to only start treatment with a PPI for four to eight weeks with patients diagnosed with GORD.
Pharmacists can play an important role in instructing patients on the correct dosage, as according to an Australian Prescriber paper, there is also poor understanding of the pharmacokinetics of PPIs with nearly 70 per cent of GPs and 20 per cent of gastroenterologists incorrectly instructing patients about when to take doses.
- Discussing deprescribing
The paper in the Australian Journal of General Practice discusses how patients may feel concerned that symptoms may return when PPIs are discontinued. The paper explains the importance of discussing the possibility of symptom return with patients. It also reports that this can be minimised with gradual dose tapering prior to discontinuation. Patients should be reassured that rebound acid hypersecretion may only last a few days and can often be adequately managed with PPI as needed or non-prescription antacids or H2 antagonists.
The Journal also explains that it would be wise, when initiating a PPI, to provide information about the intended treatment duration and follow-up. Patients who have been using PPI for the long term may not have been provided with or recall information about the intended duration. Engaging patients and carers in shared decision-making increases deprescribing success.
As part of the ‘Starting, Stepping Down and Stopping Medicines‘ program, NPS MedicineWise has also developed a consumer-tested Patient Action Plan. Health professionals can print this out and use it with their patients to help explain the importance of using lifestyle changes together with PPIs to help manage symptoms or to stop the need for future PPI treatment.
If symptoms persist after eight weeks, guidelines recommend that health professionals check adherence and dosing with patients before reassessing the need for continued treatment.
However, if symptoms do not respond to PPI treatment, patients should be referred to a specialist for further investigation.
- Lifestyle advice
Ms Sherlock says pharmacists can look at ways people can reduce their stress levels and support their nervous system’s relaxation response. “For example, more time in nature, singing, swimming, gentle movement, massage, deep breathing exercises. If people drink and smoke, linking them with adequate support to reduce these behaviours is recommended.”
References:
- https://www.gastromedicine.com.au/gastro-oesophageal-reflux-disease-gord/
- https://www.racgp.org.au/getattachment/627a9d88-5ce3-486f-b34e-a09cdaf75e94/20041128piterman.pdf
- https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/indigestion
- https://aci.health.nsw.gov.au/networks/eci/clinical/ed-factsheets/gastro-oesophageal-reflux-disease
- https://www.nps.org.au/news/stepping-the-appropriate-path-with-gord-medicines#r2
- https://www.nps.org.au/media/taking-medicines-for-gastro-oesophageal-reflux-disease-gord
- https://www.healthdirect.gov.au/gord-reflux
- https://www.nps.org.au/assets/fecfc44ab4255043-33b874b4f600-00b5f8c0e08edd00daea45f024c52354c593ec0478a723da400d7d598b24.pdf
- https://www1.racgp.org.au/ajgp/2022/november/deprescribing-proton-pump-inhibitors
- https://academic.oup.com/gastro/article/doi/10.1093/gastro/goad008/7128280
- https://www.choosingwisely.org.au/recommendations/gesa#1609
- https://australianprescriber.tg.org.au/articles/the-management-of-gastro-oesophageal-reflux-disease.html#:~:text=If%20there%20are%20no%20features,to%20withdraw%20acid%20suppression%20therapy.
This feature was written by Tracey Cheung and was originally published in the October issue of Retail Pharmacy magazine.
