How to counsel patients on heartburn treatment

Heartburn is a common ailment, with over 60 million Americans experiencing this digestive problem at least once every month. For many patients, heartburn can cause mild and temporary discomfort, especially after a large holiday meal. However, for some patients, heartburn can be a symptom of a more serious chronic condition like gastrointestinal reflux disease (GERD). Given the various over-the-counter (OTC) options for heartburn medicine, patients may be uncertain of what to choose and seek pharmacist counseling. 

Because of the numerous opportunities to counsel patients on heartburn, pharmacists are in an optimal position to guide patients on the right treatments. Continue reading to learn more about how to recommend heartburn medicine to patients. 

Assessing pharmacy patients for heartburn

Heartburn is a common gastrointestinal complaint often characterized by burping, hiccups, or pain and discomfort around the breastbone. In most cases, heartburn is mild, with many patients describing symptoms of indigestion, sour stomach, and acid regurgitation. Heartburn can also occur with other symptoms such as nausea, indigestion, and bloating. It generally occurs due to dysfunction of the lower esophageal sphincter (LES). 

Some key things to note with patients suspected of having heartburn include:

• Heartburn symptoms typically arise within an hour after eating, especially after a large meal or eating triggering foods.
• Lying down after eating may worsen heartburn symptoms.
• Patients who experience frequent heartburn around two or more times per week may have GERD.
• The severity of heartburn can be influenced by how symptoms interfere with daily activities. 

It’s important to assess patients for heartburn by asking about the severity and frequency of their symptoms. Although heartburn can be a mild occurrence, it can also develop as a symptom of certain conditions, such as GERD, peptic ulcer disease (PUD), and gallbladder disease. Doing a general work-up of patient symptoms can be key to creating a tailored OTC treatment plan. Heartburn may be complicated by ulcers, erosive esophagitis, or Barrett’s esophagus if left untreated. 

Patients should be referred to their healthcare provider if they experience heartburn for more than three months without treatment or more than two weeks with treatment with OTC medication. Patients should also be referred for abnormal or serious symptoms that accompany heartburn, such as:

• Chest pain
• Chronic cough
• Hoarseness
• Dental erosion
• Difficult or painful swallowing
• GI bleeding
• Unexplained weight loss

Understanding the patient’s symptoms can help pharmacists make informed decisions on what treatment options to recommend and whether to refer the patient to their healthcare provider. 

Counseling patients on treatment options

There are several treatment options pharmacists can recommend for treating heartburn. The goal of heartburn treatment should be to relieve symptoms, prevent the recurrence of symptoms, and reduce the risk of side effects of heartburn medicine.

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Antacids

About antacids: Antacids can be used to neutralize stomach acid and are helpful for relieving mild or infrequent heartburn. Common antacids include sodium bicarbonate, calcium carbonate, magnesium hydroxide, and aluminum hydroxide. Antacids generally work quickly (within five minutes) and can be taken at the onset of heartburn symptoms. As antacids come in numerous strengths and concentrations, it’s important to check the label of the individual product for the appropriate dosage and administration methods. 

Side effects of antacids: Magnesium-containing antacids can cause diarrhea, while aluminum- or calcium-containing antacids can cause constipation. Patients should seek medical advice from their healthcare provider if they experience severe diarrhea or constipation with antacids. If patients experience GI side effects with a particular antacid, they can opt for a different antacid. 

Drug interactions with antacids: In addition, patients should be counseled on potential drug interactions with antacids. Patients should avoid taking an antacid within two hours of certain medications, such as fluoroquinolones, tetracyclines, certain azole antifungals, and iron supplements. Taking an antacid may reduce the absorption of these medications into the body. 

H2 receptor antagonists

About H2 receptor antagonists: H2 receptor antagonists, or H2 blockers, bind to H2 receptors on gastric parietal cells to decrease stomach acid production. They are effective for treating mild to moderate heartburn. H2 blockers work quickly, within 30 to 45 minutes, and are sometimes combined with antacids for faster relief. H2 blockers include famotidine, cimetidine, and ranitidine. However, all forms of ranitidine have been recalled in the United States since 2020. 

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Patients can take H2 blockers twice daily for up to two weeks. Dosages may vary depending on the severity of symptoms. For patients with moderate heartburn, higher dosages may be recommended. 

Drug interactions with H2 receptor antagonists: Cimetidine can interact with several medications, including blood thinners, antifungals, and certain anticonvulsants and anti-anxiety drugs. Patients who take multiple medications should be assessed and counseled accordingly. Famotidine may be more suitable for patients who take medications metabolized by the cytochrome P450 system. 

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Proton pump inhibitors

About proton pump inhibitors: Proton pump inhibitors (PPIs) are effective at reducing stomach acid production and work by blocking gastric proton pumps or the H+/K+-ATPase enzyme. These medications are generally reserved for relieving mild to moderate heartburn that occurs two or more days per week. They are not typically recommended for mild or occasional heartburn. 

Compared to H2 blockers and antacids, PPIs take longer to start working but have effects that last longer. For the right candidates, pharmacists can recommend a 14-day course of treatment with a PPI taken 30 minutes before breakfast each morning. Patients generally experience symptom relief within four days of starting treatment. Tablets and capsules should not be crushed or chewed.

Drug interactions with proton pump inhibitors: Pharmacists can educate patients on potential drug interactions with PPIs and other medications. Patients taking blood thinners, antifungals, anticonvulsants, and antiviral medications may need adjustments in their treatment plan. Omeprazole, in particular, carries a risk for several drug interactions because of its extensive involvement with the cytochrome P450 system. Other options, such as pantoprazole, may carry a lower risk of drug interactions. 

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Lifestyle changes and avoiding triggers

Pharmacists can educate patients on what triggers may be causing heartburn and implement lifestyle changes as necessary. Common triggers for heartburn include foods, medications, and certain lifestyle habits, such as:

Food and beverages, including:

• Alcohol
• Caffeine 
• Chocolate
• Fatty foods
• Spicy foods
• Tomato 

Medications, including:

• Anticholinergic agents
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Barbiturates
• Calcium channel blockers
• Tricyclic antidepressants (TCAs)
• Nitrates
• Chemotherapy

Lifestyle factors, including:

• Obesity
• Stress
• Smoking
• Tight-fitting clothing
• Lying down right after eating

For patients who experience heartburn, pharmacists can recommend avoiding large meals, quitting smoking, and losing weight. In addition, patients can benefit from avoiding lying down within two to three hours after eating and using a pillow wedge to raise the head during sleep. Patients should also avoid the specific foods, beverages, and medications (if possible) that trigger their heartburn symptoms. 

If the patient is a candidate for at-home OTC treatment, pharmacists can help guide the patient on what to choose. The best treatment option will depend on the patient’s symptoms. If patients continue experiencing heartburn after two weeks of treatment, they should consult their healthcare provider for further evaluation.

Other patient considerations

Certain patients may need special attention during pharmacist counseling to choose the right heartburn medicine. Older patients are at a higher risk of experiencing complications and serious conditions that cause heartburn. Older patients may also be at a higher risk of having renal impairment, which could complicate treatment.

Pharmacists can counsel patients on avoiding aluminum- and magnesium-containing antacids due to a potential increased risk of toxicity. Pharmacists should also recommend a lower dosage of H2 blockers in patients with renal problems. Omeprazole, lansoprazole, and esomeprazole are potential PPI options for patients with renal impairment. 

For women who are pregnant with mild or infrequent heartburn, dietary and lifestyle changes can be recommended first. Antacids containing calcium and magnesium are considered safe for use during pregnancy. In addition, H2 blockers are recognized as safe during pregnancy. Omeprazole is considered low-risk during pregnancy, although animal studies have suggested the potential for fetal harm. It’s best to refer pregnant women with moderate or frequent heartburn to their primary healthcare provider. 

Being there for patients with heartburn

Patients with heartburn can greatly benefit from pharmacist counseling, especially when it comes to picking the right treatment. If you notice that the patient is purchasing an OTC antacid or PPI, it may be a good time to educate the patient to ensure they are getting the right treatment for heartburn.