Dyspepsia

Assessment and management of dyspepsia including red flags and treatment algorithms for both community pharmacist and general practitioners
Abdelwahab Ward, BS Pharm, PharmD
INTRODUCTION ã…¡ Dyspepsia is a term used to describe a collection of symptoms including upper abdominal discomfort and pain, heartburn, acid reflux (with or without bloating), nausea and vomiting related to eating. It may be caused by non-ulcer dyspepsia (diagnosis made by endoscopy), GORD, peptic ulcer disease (gastric or duodenal) or a hiatus hernia. Danger symptoms or ALARM symptoms are defined as...
    • Gastro-intestinal bleeding (may present as ‘coffee grounds’ in vomit or malaena)
    • Dysphagia (difficulty swallowing)
    • Progressive unintentional weight loss
    • Persistent vomiting
    • Also iron deficiency anemia; an epigastric mass; swallowing difficulties, anemia or suspicious barium meal, all of which may be identified by a physician examination

Symptom severity is a poor indicator of an underlying disease. In the presence of such symptoms investigations would be performed to exclude esophageal and gastric carcinoma. Anyone describing the danger symptoms listed should make an urgent appointment with their physician.

DIFFERENTIAL DIAGNOSIS

Cardiac pain is frequently mistaken for dyspeptic pain and is often difficult to distinguish – pain travelling down the arm which is not relieved by antacids is one possible distinguishing symptom and consider accompanying symptoms such as pale, cold, clammy, breathing difficulties. 

Identify other medicines that are being taken to rule out an adverse effect, e.g NSAIDs, iron, bisphosphonates or corticosteroids. Irritable bowel syndrome may also present with similar symptoms, especially accompanied by bloating, although there would usually also be abnormal bowel habits reported. Motility disorders may also be a possibility, which would require referral to the physician. Biliary colic may also present as epigastric pain precipitated by eating.

TREATMENT OPTIONS

MEDICATIONS ã…¡ There is limited evidence on the efficacy of antacids (Maalox) & Alginates (Gaviscon) in the management of dyspepsia; however, symptomatic relief is often reported with the use of an antacid or alginate. They are best given when symptoms occur or are expected, i.e after meals and at bedtime. They also remain in the stomach for longer at these times, and therefore have longer to act. Antacids should preferably not be taken at the same time as other drugs as they may impair absorption. Alginates form a ‘raft’ on the stomach contents and therefore provide symptomatic relief in reflux and protect the oesophageal mucosa, e.g. Gaviscon. For further information, see OTC options for treating gastrointestinal issues in pregnancy. Combination antacid products, containing both magnesium and aluminium salts (Maalox, Mucogel) are less likely to cause gastro-intestinal upset. Magnesium salts alone may cause diarrhea while aluminium salts alone may cause constipation.

          H2 antagonists such as ranitidine (Zantac), suppress acid secretion as a result of histamine H2 receptor blockade. The maximum single dose for OTC use is 75 to 150 mg and considered to be safe for patients who are pregnant or breastfeeding. Drug interactions with H2 receptor antagonists occur mainly with cimetidine, and its use has decreased markedly. Cimetidine inhibits CYPs (e.g., CYP1A2, CYP2C9, and CYP2D6) and thereby can increase the levels of a variety of drugs that are substrates for these enzymes. Famotidine and nizatidine are even safer in this regard.  

Proton pump inhibitors (PPIs) such as omeprazole, pantoprazole and esomeprazole. PPI inhibit gastric acid secretion by blocking the hydrogenpotassium adenosine triphosphatase enzyme system (the proton pump) of the gastric parietal cell. Proton pump inhibitors are more effective at healing than H2 antagonists or antacids. NICE (2014) states that they can be used ‘on-demand’ to relieve symptoms as they occur. They are well-tolerated drugs with side effects reported as diarrhea, headaches and dizziness. Omeprazole (Losec, Omez) 10 to 20 mg tablets may be sold for short-term relief of reflux-like symptoms in adults aged over 18 years for a maximum of four weeks. Esomeprazole (Nexium) 20 mg is licensed for adults aged 18 years and over for a maximum treatment period of 14 days.

Misoprostol (Misotac 200 mg) used as ulcer prophylaxis. Rarely used because of side effects. Cannot be used in women of childbearing potential.

  • NICE 2014 Recommendation
    1. Recommend smoking cessation and weight reduction.
    2. Consider discontinuation of offending medications (calcium channel blockers, nitrates, theophylline, bisphosphonates, steroids, and NSAIDs).
    3.     Consider testing for H. pylori after a 2-wk washout off proton pump inhibitors.
    4. Empiric trial of proton pump inhibitor therapy.
    5.     Consider laparoscopic fundoplication for patients who do not wish to continue with acid suppressive therapy long term.
    6.     Consider specialist referral for dyspepsia refractory to medications, consideration of surgery., refractory H. pylori infection and     barrett esophagus.

ALGORITHMS ã…¡ See, dyspepsia algorithms "Algorithm (1). Dyspepsia Management for community pharmacists" and "Algorithm (2). Dyspepsia Management for professional pharmacists and general practitioners".

PRACTICAL TIPS
  • If overweight, weight loss will help reduce symptoms. Smoking cessation is also sensible advice to offer which may reduce symptoms. Avoid trigger foods, e.g. chocolate, alcohol, caffeine, rich, spicy or fatty foods.
  • Pharmacological aid to weight loss. Orlistat is available OTC. It reduces dietary fat absorption and can be sold to overweight adults over 18 years of age with a BMI > 28 Kg/m2.  Overall weight loss of 5-10% of initial weight is aimed for and achieved by restricting dietary fat and reducing calorie intake along with increasing physical activity. Following a low fat diet whilst taking orlistat will reduce the incidence of side effects, such as flatulence, oily stools (with or without spotting), sudden bowel movements and steatorrhoea.

REFERENCES

Abdelwahab Ward, BS Pharm, PharmD