A Pharmacist's Guide to OTC Therapy: Upset Stomach

Almost on a daily basis, pharmacists come into contact with someone with a stomach ailment. It is important to find out what caused the patient's stomach upset and then to offer tips on how to treat it (Table 1).

Stomach Pain or Cramping

Gas, indigestion, or perhaps gastritis (an inflammation of the lining of the stomach) can cause abdominal pain. The problem can result from overeating, or it can be a reaction to alcohol, caffeine, or even medication. Diet restrictions, such as taking only bland foods and clear liquids, could relieve the symptoms.

Antacids, which are neutralizing agents, are often used to relieve the symptoms of heartburn (Table 2). For instance, the ingredient in Pepto-Bismol (bismuth subsalicylate) coats the esophagus, acts as a barrier to reflux, and alleviates pain and other symptoms. Pepto-Bismol is indicated for indigestion, heartburn, upset stomach, nausea, and diarrhea. Children with flu-like symptoms should not take it, because it can lead to Reye's syndrome.

Flatulence (Intestinal Gas)

Gas is a natural part of the digestive process. It can be caused by beans and some fruits and other vegetables. Natural products to treat gas include chamomile and peppermint. OTC formulations contain simethicone, a defoaming agent. In addition to simethicone, Flatulex, for example, contains activated charcoal, which absorbs substances that may cause gas and also relieves gas pain and bloating. New formulations of antacids and simethicone are now available (Table 3).

Beano, another product approved for treating flatulence, comes from the Aspergillus niger mold and is a solution of an enzyme known as alpha-Galactosidase. This enzyme breaks down oligosaccharides (which high-fiber foods contain) and can be a prophylactic treatment for gas caused by high-fiber foods.

Diarrhea

Diarrhea can occur as a result of a stomach virus, food poisoning, stress, and certain medications, and it can lead to dehydration. Patients should be counseled to drink plenty of clear fluids that do not contain too much sugar. In addition to diet restrictions, Pedialyte may be recommended for electrolyte loss (Table 4). If diarrhea lasts longer than 48 hours, a physician should be consulted.

Heartburn

Whereas many factors contribute to heartburn, it generally is caused by a poorly functioning lower esophageal sphincter, which allows the contents of the stomach to back up into the esophagus. Pregnancy, obesity, smoking, caffeine, alcohol, chocolate, and spicy foods may cause or aggravate heartburn.

Antacids are first-line therapy (Table 2). Taken before a meal, they provide relief for about 40 to 60 minutes, and up to 3 hours if taken after a meal. Frequent use of antacids containing aluminum, however, can cause constipation, and those containing magnesium can cause diarrhea. Antacids can affect certain medications, so it is advisable to separate doses by at least 2 hours.

Gaviscon, containing alginic acid as well as sodium bicarbonate, aluminum, and magnesium, coats the stomach. Tablets should be chewed and taken with plenty of water.

Pepcid Complete is a combination of famotidine (a histamine²-receptor antagonist [H₂RA]) and magnesium hydroxide and calcium carbonate. It offers the advantage of prompt relief from the antacids and acid reduction from the H₂RA. Experts have found that this combination offers more sustained relief.

Proton pump inhibitors (PPIs) have a longer duration of action than H₂RAs. Prilosec OTC, a 20-mg tablet, is the only PPI currently available over the counter. PPIs may interact with certain drugs, such as warfarin and diazepam, however.

Dr. Pelegrin is the pharmacy manager of a Publix Pharmacy in Miami, Fla.