Patient perspectives
I’ve been having trouble with heartburn. In fact, it is one of the reasons I wanted to lose weight. I used to get it every once in a while, but then it started to get more frequent. It used to be only in the evening, but then it started happening in the middle of the day. A burning feeling in my chest and coming up into my throat. Leaving a horrible taste in the back of my throat. Because I started getting it during the day, I had to start carrying antacid tablets around in my handbag. I haven’t been to a doctor. I found that getting my weight down to a certain level (out of the overweight range) got rid of my heartburn. It seems it doesn’t take much excess weight to push on the contents of your stomach and cause them to go up in the wrong direction.
Case 1
Mrs Amy Beston is a woman aged about 50 years who wants some advice about a stomach problem. On questioning, you find out that sometimes she gets a burning sensation just above the breastbone and feels the burning in her throat, often with a bitter taste, as if some food has been brought back up. The discomfort is worse when in bed at night and when bending over whilst gardening. She has been having the problem for 1 or 2 weeks and has not yet tried to treat it. Mrs Beston is not taking any medicines from the doctor. To your experienced eye this lady is at least a stone overweight. You ask Mrs Beston if the symptoms are worse at any particular time and she says they are worst shortly after going to bed at night.
The pharmacist’s view
This woman has many of the classic symptoms of heartburn: pain in the retrosternal region and reflux. The problem is worse at night after going to bed, as is common in heartburn. Mrs Beston has been experiencing the symptoms for about 2 weeks and is not taking any medicines from the doctor.
It would be reasonable to advise the use of an alginate antacid product about 1 h after meals and before going to bed or an H2 antagonist. Practical advice could include the tactful suggestion that Mrs Beston’s symptoms would be improved if she lost weight. If your pharmacy provides a weight management service you could ask if Mrs Beston is interested in participating. Alternatively advice on healthy eating and contact with a local weight watchers group could be given. Mrs Beston could also try cutting down on tea, coffee and, if she smokes, stopping. This is a long list of potential lifestyle changes. It might be a good idea to explain the contributory factors to Mrs Beston and negotiate with her as to which one she will begin with. Success is more likely to be achieved and sustained if changes are introduced one at a time.
Menopausal women are more prone to heartburn, and weight gain at the time of the menopause will exacerbate the problem.
The doctor’s view
The advice given by the pharmacist is sensible. Acid reflux is the most likely explanation for her symptoms. It is not clear from the presentation whether she was seeking medication or simply asking for an opinion about the cause of her symptoms, or both. It is always helpful to explore a patient’s expectations in order to produce an effective outcome to a consultation. In this instance the interchange between the pharmacist and Mrs Beston is complex as a large amount of information needs to be given, both explaining the cause of the symptoms (providing an understandable description of esophagus, stomach, acid reflux and oesophagitis) and advising about treatment and lifestyle. It is often sensible to offer a follow-up discussion to check on progress and reinforce advice. If her heartburn was not improving, it would provide an opportunity to recommend referral to her doctor.
The doctor’s next step would be very much dependent on this information. If a clear story of heartburn caused by acid reflux were obtained, then reinforcement of the pharmacist’s advice concerning posture, weight, diet, smoking and alcohol would be appropriate. If medication was requested, antacids or alginates could be tried. If the symptoms were severe, an H2 antagonist or omeprazole would be treatment options. In the case of persistent symptoms or diagnostic uncertainty, referral for endoscopy would be necessary. Helicobacter pylori eradication is not thought to play a role in the management of heartburn.
Case 2
You have been asked to recommend a strong mixture for heartburn for Harry Groves, a local man in his late fifties who works in a nearby warehouse. Mr Groves tells you that he has been getting terrible heartburn for which his doctor prescribed some mixture about 1 week ago. You remember dispensing a prescription for a liquid alginate preparation. The bottle is now empty and the problem is no better. When asked if he can point to where the pain is, Mr Groves gestures across his chest and clenches his fist when describing the pain, which he says feels heavy. You ask whether the pain ever moves and Mr Groves tells you that sometimes it goes to his neck and jaw. Mr Groves is a smoker and is not taking any other medicines. When asked if the pain worsens when bending or lying down, Mr Groves says it does not, but he tells you he usually gets the pain when he is at work, especially on busy days.
The pharmacist’s view
This man should see his doctor immediately. The symptoms he has described are not those that would be typical of heartburn. In addition, he has been taking an alginate preparation, which has been ineffective. Mr Groves’ symptoms give cause for concern; the heartburn is associated with effort at work and its location and radiation suggest a more serious cause.
The doctor’s view
Mr Groves’ story is suggestive of angina. He should be advised to contact his doctor immediately. The doctor would require more details about the pain, such as duration and whether or not the pain can come on without any exertion. If the periods of pain were frequent, prolonged and unrelieved by rest, it would be usual to arrange immediate hospital admission as the picture sounds like unstable or crescendo angina.
If an urgent inpatient referral is not required, the doctor would carry out a fuller assessment that would usually include an examination, electrocardiogram (ECG), urine analysis and blood test. This in turn could lead to medication, e.g. aspirin and glyceryl trinitrate (GTN), possibly a beta-blocker, a long acting nitrate or a rate-limiting calcium channel blocker being prescribed and an urgent outpatient referral to a cardiologist. Mr Groves would be strongly advised to stop smoking.
More detailed tests are likely to be arranged in hospital. These would probably include an exercise cardiogram and an angiogram. This latter test allows visualisation of the blood vessels supplying the heart muscle and assessment of whether surgery would be advisable.
Jennifer is a clinical pharmacologist. She helps doctors of all medical specialties choose medications. Jennifer consults about drug dosage, interactions, and side effects.