Guide Patients to Appropriate Treatments for Dyspepsia, Heartburn

Finding relief is a top priority for individuals experiencing digestive issues, and knowing when to self-treat and when to seek medical care is of paramount importance.

Most individuals experience some level of digestive discomfort associated with dyspepsia and heartburn from time to time, but others experience digestive issues and gastric discomfort regularly. Dyspepsia and heartburn, are 2 of the most common digestive complaints.¹ These symptoms may occur alone or in conjunction with other digestive issues. If left untreated, both can interrupt sleep and/or restrict or limit the amount or ingestion of certain foods; negatively affect day-to-day functioning and overall quality of life; and contribute to more severe complications, such as Barrett esophagus, esophageal cancer, esophagitis, and gastrointestinal bleeding. It is crucial that individuals with frequent heartburn receive appropriate treatment as soon as possible, because chronic heartburn may increase the risk of throat cancer, according to the American Cancer Society.^2,3

Depending upon the degree, type, and severity of symptoms, dyspepsia and heartburn may be minor inconveniences or may seriously affect quality of life. Mild to moderate dyspepsia and heartburn may be amenable to self-treatment with the use of OTC products and nonpharmacological measures.

Pharmacists are likely to encounter patients requesting advice about nonprescription products to manage dyspepsia and heartburn. Prior to recommending any nonprescription product, including antacids, histamine type 2 receptor antagonists, and proton pump inhibitors (PPIs), pharmacists should ascertain whether self-treatment is appropriate and direct those with symptoms not amenable to self-treatment to seek further medical evaluation and care immediately. Pharmacists can also help identify patients at heightened risk for developing dyspepsia and heartburn related to lifestyle habits, medical conditions, or the use of some pharmacological agents. Because of their drug expertise, pharmacists can screen for drug-drug interactions and potential contraindications and make clinical recommendations accordingly.

Dyspepsia is defined as pain that manifests in the gastroduodenal region, with hallmark signs that include burning, early satiation, epigastric pain, postprandial fullness, or upper abdominal bloating.¹ Heartburn commonly occurs with dyspepsia. Dyspepsia may be classified as organic, which has a discernible cause, or functional, which has no discernible organic systemic or metabolic disease as a cause.^1,3

Heartburn, or pyrosis, is a common symptom of gastroesophageal reflux disease (GERD), which is defined as a burning sensation arising from the substernal area and migrating toward the neck or throat.¹ There are 2 primary types: nocturnal heartburn, which occurs during sleep and is often responsible for interrupting sleep, and postprandial heartburn, which occurs within 2 hours after a meal, when bending over, or when lying down.^1,4

Heartburn is the most reported GERD symptom, according to the American College of Gastroenterology Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease.³ Patients with dyspepsia and heartburn also often describe a bitter or sour taste in the mouth; choking or coughing, especially when lying down; excessive burping; frequent interruptions of sleep caused by indigestion; a hoarse, sore throat; and regurgitation of food.¹

News and Clinical Studies

In November 2022, the FDA issued a warning regarding the use of aspirin-containing antacids and increased risk of bleeding in certain patient populations.⁵

According to findings from a study published in the Journal of Clinical Endocrinology Management, the use of PPIs is linked with elevated risks of cardiovascular events and mortality among patients with type 2 diabetes (T2D).

The authors indicated that clinicians should weigh the benefits and risks of PPIs in patients with T2D and checking of adverse cardiovascular events during PPI therapy should be increased.⁶ They also indicated that more studies are warranted.⁶

The results of a study of children published in Diagnostics show a moderate but significant association between GERD and anemia or iron deficiency.

However, larger studies are warranted to learn more about the relationship.⁷

Other research results show that an estimated 40% of women experience symptoms comparable to dyspepsia or heartburn before having a myocardial infarction. A recent article on the Harvard Health website provides valuable information about differentiating between cardiovascular disease and heartburn.⁸

The article also indicates that patients should seek medical help at an emergency department immediately when in doubt.

Essential Information to Relay During Counseling

Although most minor digestive issues can be managed with self-treatment measures, the following are examples of exclusions for self-treatment. For children, individuals taking medication for chronic conditions, or those with the following symptoms, the primary health care provider should be consulted for treatment recommendations¹:

• black, tarry stools;
• chronic hoarseness;
• difficulty swallowing food;
• nocturnal heartburn;
• persistent or recurring episodes of dyspepsia and/or heartburn for 3 months or longer and symptoms that have exacerbated or not resolved despite 14 days of self-treatment with OTC medications;
• severe dyspepsia and heartburn;
• unexplained weight loss; or
• vomiting blood.

Nonpharmacological Measures

American College of Gastroenterology guidelines recommend nonpharmacological strategies to prevent or reduce dyspepsia and heartburn.

These include the following: diet modification, such as avoiding carbonated drinks and fatty or spicy foods; losing weight; quitting smoking; and sleeping on the left side or with one’s head elevated.³

Conclusion

The goals of treating dyspepsia and heartburn include resolving symptoms and preventing the recurrence of symptoms when possible. Adherence to suggested therapy is critical, and identifying and eliminating potential triggers when feasible are essential components of themanagement plan. Encourage patients electing to use OTC products to always seek medical evaluation from their primary health care providers if they do not obtain relief from their symptoms.

References

1. Whetsel T, Zweber A. Heartburn and dyspepsia. In: Krinsky D, Berardi R, Ferreri S, et al, eds. Handbook of Nonprescription Drugs. 20th ed. American Pharmacists Association; 2021.

2. Can esophageal cancer be prevented? American Cancer Society. June 9, 2020. Accessed February 4, 2023. https://www.cancer.org/cancer/esophagus-cancer/causes-risks-prevention/prevention.html

3. Katz PO, Dunbar KB, Schnoll-Sussman FH, Greer KB, Yadlapati R, Spechler SJ. ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol. 2022;117(1):27-56. doi:10.14309/ajg.0000000000001538

4. Lee KJ. Nocturnal gastroesophageal reflux: assessment and clinical implications. J Neurogastroenterol Motil. 2011;17(2):105-107. doi:10.5056/jnm.2011.17.2.105

5. Warning: aspirin-containing antacid medicines can cause bleeding. FDA. November 7, 2022. Accessed February 4, 2023. https://www.fda.gov/consumers/consumer-updates/warning-aspirin-containing-antacid-medi-cines-can-cause-bleeding

6. Geng T, Chen JX, Zhou YF, et al. Proton pump inhibitor use and risks of cardiovascular disease and mortality in patients with type 2 diabetes. J Clin Endocrinol Metab. 2022;dgac750. doi:10.1210/clinem/dgac750

7. Lupu VV, Miron I, Buga AML, et al. Iron deficiency anemia in pediatric gas-troesophageal reflux disease. Diagnostics (Basel). 2022;13(1):63. doi:10.3390/diagnostics13010063.

8. Corliss J. Heart disease and heartburn: what’s the overlap? Harvard Health. January 1, 2023. Accessed February 7, 2023. https://www.health.harvard.edu/heart-health/heart-disease-and-heartburn-whats-the-overlap

About the Author

Yvette C. Terrie, BSPharm, RPh, is a consulting pharmacist and medical writer in Haymarket, Virginia.