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*** Greater Knox Pharmacy ***
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*** Tel: 03-9739-8951 ***

Greater Knox Pharmacy

43 Boronia Road, Boronia VIC 3155
Tel: 03-9739-8951
Email: admin@greaterknoxpharmacy.com.au
Monday8am - 7pm
Tuesday8am - 7pm
Wednesday8am - 7pm
Thursday8am - 7pm
Friday8am - 7pm
Saturday8am - 2pm
SundayClosed

1. Overview

Reflux is also known as Heartburn, Acid Reflux, Indigestion, Gastro Oesophageal Reflux Disease (GORD or GERD).

Once food is chewed and swallowed, it is pushed by muscular waves down the oesophagus (food tube) and through a sphincter (or muscle ring) into the stomach. Food can remain in the stomach from 2 to 5 hours in order to be digested. Sometimes, even in healthy individuals, the contents of the stomach squeeze up through the sphincter and back into the oesophagus. This is called 'reflux' (also known as gastro-oesophageal reflux disease, indigestion or heartburn) and feels like a burning sensation behind the breastbone.

Many people experience acid reflux from time to time. GERD is mild acid reflux that occurs at least twice a week, or moderate to severe acid reflux that occurs at least once a week.

Most people can manage the discomfort of reflux with lifestyle changes and over-the-counter medications. People with GERD may need stronger medications or rarely, surgery to ease symptoms.

2. Causes and Risk Factors

  • Obesity
  • Smoking
  • Eating large meals or eating late at night
  • Drinking certain beverages, such as alcohol or coffee
  • Pregnancy
  • Eating certain foods (triggers - see below)
  • Taking certain medications (see below)
  • Bulging of the top of the stomach up into the diaphragm (hiatal hernia)
  • Connective tissue disorders, such as scleroderma
  • Delayed stomach emptying

2.1 Foods that can relax the Lower Esophageal Sphincter (LES)

  • Coffee (with or without caffeine) and caffeinated beverages relax the lower esophageal sphincter.
  • Citrus fruits and juices such as orange, grapefruit and pineapple have high acid content.
  • Tomatoes and processed tomato-based products such as tomato juice, and pasta and pizza sauces are highly acidic.
  • Carbonated beverages (fizzy drinks) cause gaseous distension of the stomach (bloating) which increases pressure on the lower esophageal sphincter causing acid reflux.
  • Sports drinks (due to their potassium content) can irritate the oesophagus.
  • Chocolate contains a chemical called methylxanthine from the cocoa tree, which is similar to caffeine. It relaxes the lower esophageal sphincter, which causes acid reflux.
  • Peppermint, garlic and onion relax the lower esophageal sphincter causing acid reflux.
  • Fatty, spicy or fried foods relax the lower esophageal sphincter as well as delay stomach emptying and therefore cause acid reflux.

2.2 Medicines that can cause reflux

  • Antibiotics such as Tetracycline, Doxycycline, Minocycline, Clindamycin
  • Anticholinergics such as Ditropan (Oxybutynin), Benadryl (Diphenhydramine), Benztrop (Benzatropine), Largactil (Chlorpromazine), Periactin (Cyproheptadine), Dothep (Dosulepin previously known as Dothiepin), Phenergan (Promethazine)
  • Benzodiazepines such as Valium (Diazepam), Tamaze (Temazepam)
  • Bisphosphonates such as Fosamax (Alendronate), Actonel (Risedronate)
  • Calcium Channel Blockers such as Norvasc (Amlodipine), Adalat (Nifedipine), Felodur (Felodipine), Cardizem and Vasocardol (Diltiazem), Zanidip (Lercanidipine), Cordilox, Isoptin and Anpec (Verapamil)
  • Corticosteroids such as Dexmethsone (Dexamethasone), Panafcortelone, Predmix, Redipred and Solone (Prednisolone), Panafcort, Sone and Predsone (Prednisone)
  • Iron supplements such as Ferro-tab, Ferro-Grad, Maltofer, Ferro-Liquid
  • Nicotine replacement therapy such as Nicotinell, Nicorette, Nicabate
  • Nitrates such as Anginine and Lycinate (Glyceryl trinitrate), Isordil (Isosorbide dinitrate), Imdur and Monodur (Isosorbide mononitrate)
  • Non-steroidal anti-inflammatory drugs (NSAIDs) such as Aspirin, Nurofen and Advil (Ibuprofen), Voltaren (Diclofenac), Ponstan (Mefenamic acid), Naprogesic, Proxen and Inza (Naproxen), Arthrexin and Indocid (Indomethacin), Celebrex (Celecoxib), Mobic (Meloxicam)
  • Opioid analgesics such as Codeine and Methadone
  • Potassium supplements such as Span-K, Duro-K and Chlorvescent (Potassium Chloride)
  • Progesterone
  • Quinidine
  • Theophylline
  • Tricyclic antidepressants such as Endep (Amitriptyline), Anafranil (Clomipramine), Tofranil (Imipramine), Allegron (Nortriptyline), Dothep (Dosulepin previously known as Dothiepin)
  • Warfarin such as Coumadin, Marevan

3. Symptoms

Common signs and symptoms of reflux and GERD include:

  • A burning sensation in the chest (heartburn), usually after eating, which might be worse at night
  • Chest pain
  • Difficulty swallowing
  • Regurgitation of food or sour liquid
  • Sensation of a lump in the throat
  • Cavities
  • Bad breath
  • Sudden excess of saliva
  • Inflammation of the gums

If you have nighttime acid reflux, you might also experience:

  • Chronic dry cough
  • Laryngitis
  • New or worsening asthma
  • Disrupted sleep

⚠ 3.1 RED FLAGS 🚩🚩🚩

Some symptoms may require urgent medical attention:

  • Chest pain with shortness of breath, pain in the jaw, arm, neck or shoulder
  • Any sign of stomach bleeding such as dark, tarry or sticky faeces or vomiting of blood that is bright red or has the appearance of coffee grounds
  • Unexplained weight loss
  • Difficult or painful swallowing
  • Recurrent vomiting

3.2 See your doctor if you have any of the following:

  • New symptoms in a person aged >55 years
  • Changing, severe or frequent (> twice/week) symptoms
  • Symptoms not adequately controlled or continuing after a 2 week trial of H2-blocker or proton pump inhibitor
  • Prolonged use of proton pump inhibitors without medical investigation
  • Abdominal pain.

4. Diagnosis

Diagnosis is usually made based on symptoms, medical history and physical examination. A diagnosis can be confirmed with a two week trial of reflux medication.

When a patient experiences common symptoms of gastroesophageal reflux disease, namely heartburn and/or acid regurgitation, additional tests prior to starting treatment are typically unnecessary. If symptoms do not respond to treatment, or if other symptoms such as weight loss, trouble swallowing or internal bleeding are present, additional testing may be necessary.

To confirm a diagnosis of GERD, or to check for complications, your doctor might recommend:

  • Upper endoscopy.
  • Ambulatory acid (pH) probe test.
  • Esophageal manometry.
  • X-ray of your upper digestive system.

5. Treatment

Treatment should always start with reducing or eliminating causes and risk factors. Some measures include:

  • Eating smaller meals
  • Not eating at least 2 hours before bedtime
  • Raising the bed head (if symptoms occur mainly at night)
  • Avoid tight clothing
  • Reducing weight
  • Quitting smoking
  • Avoid alcohol, coffee and trigger foods
  • Avoid lying down after eating
  • Ask your doctor about changing or stopping medications that may be causing reflux.

5.1 Mild Intermittent Symptoms (one episode per week)

Most symptoms can be managed with lifestyle modifications. If symptoms are not sufficiently controlled, then an initial trial of antacids is appropriate. Antacid tablets are less effective than liquid preparations but are more convenient.

If antacids do not give adequate relief, use either an H2-receptor antagonist or a proton pump inhibitor (PPI) at the standard dose.

5.2 Frequent or severe symptoms (GORD - two or more episodes per week)

** Seek medical advice from your doctor. **

Patients often need regular drug therapy in addition to diet and lifestyle modification.

5.2.1 Initial Therapy

Start with a proton pump inhibitor (PPI) at standard dose. PPIs are generally preferred to H2-receptor antagonists for initial therapy. Response to a trial of PPI therapy can confirm the diagnosis.

The initial course of treatment should be 4 to 8 weeks. When symptom control is adequate, step down to maintenance therapy.

5.2.2 Maintenance Therapy

If initial PPI therapy provides adequate symptom control, therapy may be titrated down and continued at the lowest dose and frequency that controls symptoms, or stopped.

If symptoms recur during step-down therapy, advise patients to return to the lowest PPI dosage that provided effective symptom control.

Symptom recurrence may be prevented by gradually reducing the PPI dose before stopping, or using on-demand or regular therapy with an H2-receptor antagonist or antacid.

5.3 Antacids

They work to neutralise the acid in the stomach. They act fairly quickly and last between 2-6 hours. Take between meals or at bedtime when symptoms occur or you expect they might occur. Tablets should be chewed or sucked before swallowing for the best effect. Liquids work better than tablets, but are less convenient.

Antacids can reduce the effect of a number of other medicines taken by mouth. The best way to avoid a problem is to separate taking antacids and other medicines by at least 2 hours.

Brand Ingredients Form Pregnancy Breastfeeding Available
Gaviscon Dual Action Alginate, Sodium Bicarbonate, Calcium Carbonate Liquid, Chewable Tablets Category A
Safe
Safe OTC
Gaviscon Double Strength Alginate, Potassium Bicarbonate, Calcium Carbonate Liquid Category A
Safe
Safe OTC
Mylanta 2go Double Strength Aluminum Hydroxide, Magnesium Hydroxide, Simethicone Chewable Tablets Category A
Safe
Safe OTC

5.4 H2-receptor antagonists

They reduce acid production from the stomach, and provide longer relief than antacids for up to 12 hours even though they don’t work quite as fast.

Brand Ingredients Form Pregnancy Breastfeeding Available
Ausfam Famotidine 20mg once or twice daily as required Tablets Category B1, Probably Safe Considered Safe Prescription
Tacidine, Nizac Nizatidine 150mg once or twice daily as required Tablets Category B3, Probably Safe Considered Safe Prescription
Zantac Ranitidine 150mg once or twice daily as required Tablets Category B1, Probably Safe Considered Safe Discontinued

5.5 Proton pump inhibitors (PPIs) - Standard dose

Pregnancy: Category B3. If antacids and H2-blockers are ineffective, use Omeprazole.
Breastfeeding: If antacids and H2-blockers are ineffective, use Omeprazole.

They block acid production and heal the oesophagus. They are stronger acid blockers than H2-receptor antagonists.

Brand Ingredient and dose Form Available
Nexium Esomeprazole 20mg once daily Tablets, Capsules OTC, Prescription
Zoton Lansoprazole 30mg once daily Tablets Prescription
Losec, Acimax Omeprazole 20mg once daily Tablets, Capsules Prescription
Somac Pantoprazole 40mg once daily Tablets, Granules Prescription
Pariet Rabeprazole 20mg once daily Tablets Prescription

5.6 Proton pump inhibitors (PPIs) - Over the Counter

Some PPIs are available at pharmacies without a doctor’s prescription. They usually come at a lower dose than the prescription strength and in smaller packs. They can be used for managing mild intermittent symptoms.

Brand Ingredient and dose Form Pack Size Available
Nexium Esomeprazole 20mg once daily Tablets, Capsules 7, 14 OTC
Somac Pantoprazole 20mg once daily Tablets 7, 14 OTC
Pariet Rabeprazole 10mg once daily Tablets 7 OTC

6. References

  1. Better Health Channel
  2. Mayo Clinic
  3. How To Treat Heartburn
  4. University of Wisconsin Hospitals and Clinics - Department of Nursing
  5. Australian Medical Handbook, July 2020
  6. American Academy of Allergy, Asthma & Immunology
  7. NPS MedicineWise
  8. myDr.com.au
  9. Australian Formulary and Handbook (APF24)
  10. American Society for Gastrointestinal Endoscopy