Heartburn

Abstract

Heartburn and acid regurgitation are the classic symptoms of gastroesophageal reflux disease (GERD). Heartburn is defined as a burning sensation in the retrosternal area (behind the breastbone) and regurgitation is the perception of flow of refluxed gastric content into the mouth or hypopharynx. GERD is the most prevalent acid-related disorder in Canada and affects 10–30% of the population in the United States and Europe. Assessment of the patient with heartburn requires knowledge of characteristic, atypical, and nonspecific symptoms, as well as the red flags that may indicate a more sinister underlying cause (e.g., gastric carcinoma) and require referral to a physician for further workup. It is important to determine if the patients’ heartburn symptoms could be caused by an underlying medical condition that, in some cases, could be life-threatening (e.g., cardiac chest pain). Patients presenting to the community pharmacist with classic heartburn or regurgitation in the absence of red flags can confidently self-treat their symptoms with various over-the-counter (OTC) acid-lowering products, including proton pump inhibitors (PPI), without requirement for further referral or investigation. Patients should be advised to follow-up with their pharmacist or physician if their symptoms persist after a 2–4-week trial of OTC therapy. Patients presenting with new epigastric pain as their predominant symptom (i.e., undiagnosed dyspepsia) should be referred to their physician for further assessment. Therapy for GERD is typically limited to 4–8 weeks, but chronic use of PPI therapy is common. In these situations, it is important to assess the patient history, as there are several indications where continued long-term PPI therapy is appropriate (e.g., Barrett’s esophagus, chronic NSAID users with bleeding risk, severe esophagitis, and documented history of bleeding ulcers). In the absence of these indications, lowering the dose or stopping PPI therapy may be appropriate.