Guidance on the use of over-the-counter proton pump inhibitors for the treatment of GERD

Impact of a pharmaceutical algorithm on patients with upper-gastrointestinal symptoms: A pre-post intervention study

OBJECTIVE

To evaluate the algorithm impact on the upper gastrointestinal patients' symptoms (PROMs) and satisfaction with pharmaceutical care received (PREMs).

METHODS

The algorithm was previously developed by clinicians and pharmacists, through a pre-post intervention study in Spain (June-October 2022). We included 1221 patients who were seeking advice and/or medication for symptoms at 134 community pharmacies. Patients' sociodemographic and clinical variables were assessed at baseline and were classified in accordance with the Gastroesophageal Reflux Disease Impact Scale (GIS) into patients with either epigastric, retrosternal or overlapping symptoms. Interventions included medical referral; education on healthy habits; prescription of an OTC treatment or a non-pharmacologic prescription. Fourteen days later, patients were assessed through: a) the change on the GIS score, and b) patients' satisfaction with pharmaceutical care received.

RESULTS

Most patients reported overlapping symptoms (660, 54.0%), 171 (14.0%) reported epigastric symptoms and 390 (32.0%) retrosternal symptoms. Patients with epigastric symptoms did not show a difference in the GIS score after the intervention while those with retrosternal symptoms and those with overlapping symptoms did (mean 1.09 (4.28 SD), p < 0.001 and mean 3.18 (6.01 SD), p < 0.001, respectively). Patients who received education on healthy habits and those with a prescription of a pharmacological treatment (antiacids in monotherapy and alginates-antiacids) showed an increase in the GIS score. Patients' satisfaction with pharmaceutical care received was over 99.2% of sample.

CONCLUSION

Implementation of the upper-gastrointestinal symptoms algorithm in Community pharmacies had a positive impact on patients' symptoms, quality of life, and satisfaction with pharmaceutical care received.

Prevalence and risk factors of upper gastrointestinal symptoms in community pharmacies in Spain: a cross-sectional study

Background: Frequently, the community pharmacies are the only points of consultation for upper-gastrointestinal symptomology. However, the heterogeneity of symptoms often limits the correct management of the patient. The study aim is to describe the epidemiological and clinical characteristics of patients with upper-gastrointestinal symptoms who ask for advice in community pharmacies. Methods: A cross-sectional study was performed in 134 Spanish pharmacies (June-October 2022) and we included 1,360 patients. We collected sociodemographic, clinical variables and current medication data. The pharmacist evaluated the gastrointestinal symptoms through the application of the GERD Impact Scale (GIS questionnaire). Patients were classified into three groups according to their symptoms: epigastric, retrosternal and overlapping symptoms. Results: Median age was 49 years (interquartile range 36-62 years) and 59.3% were women. Most patients reported overlapping symptoms (738%, 54.3%), 433 (31.8%) retrosternal and 189 (13.9%) epigastric symptoms. Patients with overlapping symptoms were more likely to associated consumption of foods and/or drinks and symptoms and showed lower scores on the GIS scale (median 26, IQR 20-30) than those with epigastric (median 32, IQR 29-33) and retrosternal (median 32, IQR 28-34) symptoms (p < 0.001). Patients in treatment with a combination of alginates and antiacids were more likely to think that it better alleviated their symptoms in all the patients included (p = 0.012). Conclusion: More than half of the patients showed overlapping symptoms and were more likely to associate their symptoms with dietary habits and having poorer scores in the GIS scale. Clinical awareness of such overlapping condition would help optimize the management of patients with upper gastrointestinal symptoms in practice.

The management of upper gastrointestinal symptoms: A study on community pharmacies in Italy

Upper gastrointestinal (GI) symptoms are usual complaints among patients presenting to Italian community pharmacies. However, information on treatment history of those patients is often lacking. This descriptive, cross-sectional study aims at exploring the medication history of individuals with upper GI tract symptoms visiting one of the 20 enrolled community pharmacies, over a period of 7 months, based on the administration of a questionnaire. Of 1,020 interviewees, 62.1% had asked for a medical consultation. The most frequent symptom was epigastric burning (31.8%), followed by acid regurgitation (14.6%) and post-prandial fullness (12.0%). Of the 1,609 therapies, proton pump inhibitors constituted the most represented therapeutic class (35.6%) followed by antacids (17.5%) and alginate-based products (17.2%). In treating symptoms, 38.1% of the patients do not seek medical advice, while 42.0% rely on non-prescription therapies. As findings suggest, support to patients with GI disorders in community pharmacies can be enhanced for a safer self-medication.

Therapeutic Efficacy of Kangfuxin Liquid Combined with PPIs in Gastric Ulcer

Objective

To evaluate the clinical efficacy and safety of Kangfuxin liquid (KFX) combined with proton pump inhibitors (PPIs) in the treatment of gastric ulcer (GU).

Materials and Methods

Electronic databases including PubMed, Wanfang, CNKI, VIP, Embase, Cochrane Library, and CBM were examined for appropriate articles without language limitations on key words before March 10, 2019. RevMan 5.3 software was applied to execute outcome assessment and finish the meta-analysis.

Results

22 articles involving 2,024 patients with a gastric ulcer were selected. Total efficacy rate and efficacy rate of gastroscopy were significantly enhanced for the combination of KFX with PPIs compared to those of PPI treatment alone (OR = 6.95, 95% CI: 4.87, 9.91, P < 0.00001; OR = 2.96, 95% CI: 1.98, 4.42, P < 0.00001, respectively). Same results were found for different PPIs in combination on total efficacy rate, respectively. The combination also significantly reduced the adverse events (OR = 0.39, 95% CI: 0.22, 0.70, P=0.002). In addition, KFX combined with PPI could suppress the inflammation (MD = −6.11, 95% CI: −7.45, −4.77, P < 0.00001), reduce the recurrence rate (OR = 0.31, 95% CI: 0.14, 0.70, P=0.005), and enhance the clearance rate of Helicobacter pylori (HP, OR = 3.76, 95% CI: 1.80, 7.87, P=0.0004). It seemed like the combination would influence immune function by increasing levels of T-lymphocyte subsets CD4 and CD8 but not CD3 (MD = 2.40, 95% CI: 1.25, 3.55, P < 0.0001); MD = 25.72, 95% CI: 14.55, 36.90, P < 0.00001; MD = 0.72, 95% CI: −0.66, 2.09, P=0.31, respectively).

Conclusion

KFX combined with PPIs in treatment of patients with GU could improve the total efficacy rate and efficacy rate of gastroscopy and reduce adverse events and the recurrence rate. However, the results of this study should be handled with care due to the limitations. Several rigorous RCTs are in need to confirm these findings.

Attitude and knowledge of Saudi community pharmacists towards use of proton pump inhibitors

Introduction

Proton pump inhibitors (PPIs) effectively suppress acid secretion and play an important role in peptic ulcer disease and gastroesophageal reflux disease. There is a real concern about the overutilization of PPIs, which will lead to significant high cost and undesirable outcomes. Despite that most of PPIs are classified as prescribed medications, yet most of their users take them without prescription in Saudi Arabia. Therefore, it was important to understand community pharmacists practice in dealing with PPIs and to evaluate their despising pattern of these medications.

Method

A cross-sectional survey-based study that was carried out between September and December 2017. The survey intended to evaluate the knowledge and attitude of CPs towards use of proton pump inhibitors and was built as an online survey.

Results

The results of this study showed that almost all CPs prescribe anti-ulcer drugs for their patients. Most of the participants (68.4%) have prescribed PPI for acute gastritis (68.4%), prophylaxis for stress ulcers (17.7%) and stress ulcer (11.1%). 54.9 percent of the participants recommend using acid suppression drugs for 1 to 2 weeks when they prescribe them to their patients. Thirty-two percent of the respondents had reported adverse events with PPIs. The study showed a significant association between length of work experience in community pharmacy and reporting adverse events.

Conclusion

Community pharmacists in Saudi Arabia usually recommend and prescribe PPIs to their patients. Most of them have some knowledge on PPIs indications and side effects. Managing OTC PPI use in the community pharmacy setting is necessary to promote both patient and medication safety.

Management of gastroesophageal reflux disease in adults: a pharmacist's perspective

Gastroesophageal reflux disease (GERD) is a common gastrointestinal diagnosis, a leading reason for endoscopy and cause of potentially serious complications, resulting in significant individual and system-wide health burden. Approximately one quarter of people living in western countries have experienced GERD, and the prevalence appears to be on the rise. Risk factors for GERD include hiatus hernia, obesity, high-fat diet, tobacco smoking, alcohol consumption, pregnancy, genetics, and some medications. The cardinal symptoms of GERD are troublesome heartburn and regurgitation. GERD is identified by taking a patient-centered history and if necessary can be classified by endoscopic investigation. The role of the pharmacist in the management of GERD is to confirm the diagnosis by history taking, confirm there are no alarming signs or symptoms that require referral to a doctor, and recommendation of short-term therapy to control symptoms. Effective pharmacological treatments for GERD include antacids, alginate, histamine H2 receptor antagonists, and proton pump inhibitors. This narrative review includes a comparison of the efficacy and safety of these treatments and pertinent information to help pharmacists advise patients with GERD on their appropriate use.

The Safety of Appropriate Use of Over-the-Counter Proton Pump Inhibitors: An Evidence-Based Review and Delphi Consensus

The availability of over-the-counter (OTC) proton pump inhibitors (PPIs) for the short-term (2 weeks) management of frequent heartburn (≥2 days/week) has increased markedly, yet evidence-based recommendations have not been developed. A panel of nine international experts in gastroesophageal reflux disease developed consensus statements regarding the risks and benefits of OTC PPIs using a modified Delphi process. Consensus (based on ≥80% approval) was reached through multiple rounds of remote voting and a final round of live voting. To identify relevant data, the available literature was searched and summarized. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system terminology was used to rate the quality of evidence and strength of recommendations; consensus was based on ≥2/3 agreement. After 4 rounds of review, consensus was achieved for 18 statements. Notably, the available data did not directly reflect OTC use, but instead, prescription use; therefore, extrapolations to the OTC setting were often necessary. This limitation is regrettable, but it justifies performing this exercise to provide evidence-based expert opinion on a widely used class of drugs. The panel determined that using OTC PPIs according to label instructions is unlikely to mask the symptoms of esophageal or gastric cancer or adversely impact the natural history of related precursor conditions. OTC PPIs are not expected to substantially affect micronutrient absorption or bone mineral density or cause community-acquired pneumonia, Clostridium difficile infection, or cardiovascular adverse events. However, OTC PPI use may be associated with slightly increased risks for infectious diarrhea, certain idiosyncratic reactions, and cirrhosis-related spontaneous bacterial peritonitis. The available evidence does not suggest that OTC PPI use consistent with label instructions is associated with substantial health risks. To minimize potential risks, healthcare professionals and consumers must actively participate in decision making when managing reflux-related symptoms in the self-care setting.

Effective and safe proton pump inhibitor therapy in acid-related diseases - A position paper addressing benefits and potential harms of acid suppression

BACKGROUND

The introduction of proton pump inhibitors (PPIs) into clinical practice has revolutionized the management of acid-related diseases. Studies in primary care and emergency settings suggest that PPIs are frequently prescribed for inappropriate indications or for indications where their use offers little benefit. Inappropriate PPI use is a matter of great concern, especially in the elderly, who are often affected by multiple comorbidities and are taking multiple medications, and are thus at an increased risk of long-term PPI-related adverse outcomes as well as drug-to-drug interactions. Herein, we aim to review the current literature on PPI use and develop a position paper addressing the benefits and potential harms of acid suppression with the purpose of providing evidence-based guidelines on the appropriate use of these medications.

METHODS

The topics, identified by a Scientific Committee, were assigned to experts selected by three Italian Scientific Societies, who independently performed a systematic search of the relevant literature using Medline/PubMed, Embase, and the Cochrane databases. Search outputs were distilled, paying more attention to systematic reviews and meta-analyses (where available) representing the best evidence. The draft prepared on each topic was circulated amongst all the members of the Scientific Committee. Each expert then provided her/his input to the writing, suggesting changes and the inclusion of new material and/or additional relevant references. The global recommendations were then thoroughly discussed in a specific meeting, refined with regard to both content and wording, and approved to obtain a summary of current evidence.

RESULTS

Twenty-five years after their introduction into clinical practice, PPIs remain the mainstay of the treatment of acid-related diseases, where their use in gastroesophageal reflux disease, eosinophilic esophagitis, Helicobacter pylori infection, peptic ulcer disease and bleeding as well as, and Zollinger-Ellison syndrome is appropriate. Prevention of gastroduodenal mucosal lesions (and symptoms) in patients taking non-steroidal anti-inflammatory drugs (NSAIDs) or antiplatelet therapies and carrying gastrointestinal risk factors also represents an appropriate indication. On the contrary, steroid use does not need any gastroprotection, unless combined with NSAID therapy. In dyspeptic patients with persisting symptoms, despite successful H. pylori eradication, short-term PPI treatment could be attempted. Finally, addition of PPIs to pancreatic enzyme replacement therapy in patients with refractory steatorrhea may be worthwhile.

CONCLUSIONS

Overall, PPIs are irreplaceable drugs in the management of acid-related diseases. However, PPI treatment, as any kind of drug therapy, is not without risk of adverse effects. The overall benefits of therapy and improvement in quality of life significantly outweigh potential harms in most patients, but those without clear clinical indication are only exposed to the risks of PPI prescription. Adhering with evidence-based guidelines represents the only rational approach to effective and safe PPI therapy. Please see related Commentary: doi: 10.1186/s12916-016-0724-1 .

Changes in Prescription and Over-the-Counter Medication and Dietary Supplement Use Among Older Adults in the United States, 2005 vs 2011

IMPORTANCE

Prescription and over-the-counter medicines and dietary supplements are commonly used, alone and together, among older adults. However, the effect of recent regulatory and market forces on these patterns is not known.

OBJECTIVES

To characterize changes in the prevalence of medication use, including concurrent use of prescription and over-the-counter medications and dietary supplements, and to quantify the frequency and types of potential major drug-drug interactions.

DESIGN, SETTING, AND PARTICIPANTS

Descriptive analyses of a longitudinal, nationally representative sample of community-dwelling older adults 62 to 85 years old. In-home interviews with direct medication inspection were conducted in 2005-2006 and again in 2010-2011. The dates of the analysis were March to November 2015. We defined medication use as the use of at least 1 prescription or over-the-counter medication or dietary supplement at least daily or weekly and defined concurrent use as the regular use of at least 2 medications. We used Micromedex to identify potential major drug-drug interactions.

MAIN OUTCOMES AND MEASURES

Population estimates of the prevalence of medication use (in aggregate and by therapeutic class), concurrent use, and major drug-drug interactions.

RESULTS

The study cohort comprised 2351 participants in 2005-2006 and 2206 in 2010-2011. Their mean age was 70.9 years in 2005-2006 and 71.4 years in 2010-2011. Fifty-three percent of participants were female in 2005-2006, and 51.6% were female in 2010-2011. The use of at least 1 prescription medication slightly increased from 84.1% in 2005-2006 to 87.7% in 2010-2011 (P = .003). Concurrent use of at least 5 prescription medications increased from 30.6% to 35.8% (P = .02). While the use of over-the-counter medications declined from 44.4% to 37.9%, the use of dietary supplements increased from 51.8% to 63.7% (P < .001 for both). There were clinically significant increases in the use of statins (33.8% to 46.2%), antiplatelets (32.8% to 43.0%), and omega-3 fish oils (4.7% to 18.6%) (P < .05 for all). In 2010-2011, approximately 15.1% of older adults were at risk for a potential major drug-drug interaction compared with an estimated 8.4% in 2005-2006 (P < .001). Most of these interacting regimens involved medications and dietary supplements increasingly used in 2010-2011.

CONCLUSIONS AND RELEVANCE

In this study, the use of prescription medications and dietary supplements, and concurrent use of interacting medications, has increased since 2005, with 15% of older adults potentially at risk for a major drug-drug interaction. Improving safety with the use of multiple medications has the potential to reduce preventable adverse drug events associated with medications commonly used among older adults.

Surgical treatment of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a very common foregut disease prevalent worldwide. The prevalence of GERD has risen strikingly over the past decades, causing substantial health and economic burdens. Due to high rates of recurrent reflux symptoms, reoperations and complications, surgical therapy of GERD did not attach enough attention in its early stage. However, surgical therapy for GERD was subsequently revolutionized by the development of anti-reflux surgical techniques and the introduction and popularization of minimally invasive surgeries. Anti-reflux surgery has gradually proved to be a well-documented, effective, therapeutic option for GERD by long-term follow-up studies. In order to improve results and to reduce unwanted effects, surgeons should master the indications of surgery and techniques of anti-reflux surgery. Besides, choosing appropriate candidates and surgical approach is also crucial for outcomes. However, limited by the regional economy and surgeon's skill, the use of anti-reflux surgery is still very limited. The aim of this review is to analyze and discuss the current spectrum of surgical therapy of GERD, and to provide orientation for surgeons in the challenging therapy of GERD.

The role of the pharmacist in the selection and use of over-the-counter proton-pump inhibitors

Background Heartburn and other symptoms of gastro-oesophageal reflux occur in ~30 % of survey respondents in multiple countries worldwide. Heartburn and acid regurgitation are common complaints in the pharmacy, where patients frequently seek relief through medication and advice. The growing number of proton-pump inhibitors available in the over-the-counter setting provides an efficacious choice to patients experiencing frequent heartburn. Pharmacists can assist patients in their treatment decisions whilst inquiring about alarm symptoms that should prompt a physician referral. Aim of the review Provide pharmacists with a review of current clinical research and expert guidelines on use of over-the-counter proton-pump inhibitors. Methods This narrative review was conducted to identify publications relevant to the following themes: overview of available treatments for frequent episodes of heartburn/acid regurgitation; treatment algorithms providing guidance on when to use over-the-counter proton-pump inhibitors; and the role of the pharmacist in the use of over-the-counter proton-pump inhibitors. Results Frequent symptoms of acid reflux, such as heartburn and acid regurgitation, can interfere substantially with daily life activities. Proton-pump inhibitors are the most efficacious treatment for frequent reflux symptoms and are recommended as an appropriate initial treatment in uncomplicated cases. Proton-pump inhibitors have varying pharmacokinetics and pharmacodynamics across the class; 20 mg esomeprazole has higher bioavailability and exposure than over-the-counter omeprazole, for example. However, differences in clinical efficacy for symptom relief have not been demonstrated. The safety and tolerability of proton-pump inhibitors have been well established in clinical trial and post-marketing settings, and use of a short regimen is associated with a very low likelihood of missing a more serious condition. Pharmacists can assist patients with accurate self-diagnosis by asking short, simple questions to characterize the nature, severity, and frequency of symptoms. Additionally, pharmacists can inquire about alarm symptoms that should prompt referral to a physician. Pharmacists should inform those patients for whom over-the-counter proton-pump inhibitors are appropriate on their proper use. Conclusion Over-the-counter proton-pump inhibitors have a valuable role in the treatment of frequent heartburn. Pharmacists have the opportunity to guide patients through selection of the best treatment option for their symptoms.

Non-prescription treatment of NSAID induced GORD by Australian pharmacies: a national simulated patient study

BACKGROUND

Patients regularly present to community pharmacies for advice about and treatment for reflux symptoms and NSAIDs are a common cause of these symptoms. There is no published literature detailing the approach that pharmacies take to these enquiries, the pharmacotherapy they recommend or whether they contribute to the safe and effective use of reflux medicines.

OBJECTIVES

To assess in an observational study design the clinical history gathering, recommendations for GORD management and counselling provided by community pharmacies in a simulated patient scenario involving suspected NSAID induced reflux symptoms. Setting Australian community pharmacies.

METHOD

Simulated patients visited 223 community pharmacies to request treatment for reflux symptoms. The interaction was audiotaped and assessed against guidelines for the treatment of reflux symptoms.

MAIN OUTCOME MEASURES

Alignment of community pharmacies with international expert gastroenterologist guidance and national professional practice guidelines for the treatment of reflux symptoms by pharmacists including: consultation with a pharmacist; confirmation of reflux diagnosis based on symptoms; recommendation of short courses proton pump inhibitor (PPI) therapy; advice on the safe and effective use of reflux medicines and referral to a doctor for further assessment.

RESULTS

Pharmacists consulted with the simulated patient in 77% of cases. Symptoms were enquired about in 95% of cases and a medicines history taken in 69% of cases. Recommendations for treatment included: PPIs (18%), histamine H2 antagonists (57%) and antacids (19%). Advice on product use was given in 83% of cases. Referral to a doctor to discuss reflux symptoms was made in 63% of cases.

CONCLUSION

When assessing patients for the symptoms of GORD, Australian pharmacists and non-pharmacist support staff take a comprehensive history including symptomatology, duration of symptoms, concomitant medicines and medical conditions and any GORD treatments previously trialled. They provide comprehensive counselling on the use of antisecretory and antacid medicines. Counselling could involve more comprehensive information on lifestyle approaches for GORD management and side effects of antisecretory and antacid medicines. Further alignment with guidelines for the management of GORD would result in greater referral to a doctor for assessment of recurrent GORD and greater recommendation of PPIs for symptoms. However alignment with guidelines by all pharmacists is unrealistic if the guidelines are not universally available to them.

Partnership in optimizing management of reflux symptoms: a treatment algorithm for over-the-counter proton-pump inhibitors

BACKGROUND

Uncomplicated heartburn and acid regurgitation are increasingly treated and managed using over-the-counter medications. However, with over-the-counter availability of antacids, alginates, histamine 2 receptor antagonists (H2RAs), and proton-pump inhibitors (PPIs), consumers need guidance as to appropriate options and how to use them.

METHODS

Relevant guidelines, studies, and reviews were identified via literature searches of PubMed/Medline and Google Scholar, as well as cross-referencing from the identified papers.

RESULTS

Antacids, alginates, and H2RAs are best suited to management of occasional heartburn, taken either before provocative meals or other triggers or on demand when symptoms arise. Over-the-counter PPIs are appropriate options across the range of symptom severity/frequency typically encountered in the pharmacy, but may be particularly appropriate for treatment of those with frequent and/or very bothersome heartburn. A 2-4 week course of daily PPIs can lead to complete resolution of frequent heartburn. Counseling is important to ensure that patients understand that failure of symptoms to resolve or a rapid return of symptoms while taking a PPI is an indication to consult a doctor, whereas a return of symptoms after a period of months may be an indication for just another course of treatment. The need for effective communication and for ensuring use of the correct medication in the over-the-counter setting puts much of the responsibility for management of heartburn and acid regurgitation on the pharmacist. A proposed algorithm that details when and how to use available over-the-counter medications is presented. This algorithm also highlights alarm features and atypical symptoms indicative of other underlying conditions that should be referred directly to a physician.

CONCLUSION

Implementation of a simple algorithm will empower pharmacists and consumers alike and ensure consistent and appropriate care.