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"On a scale of 0 to 10, with 0 being no pain and 10 being the worst pain you can imagine, how would you rate your headache right now?"

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Does the patient have all or any of the following symptom?

  • Chest pain (retrosternal) radiating to shoulder, arm, neck, or jaw
  • Precipitated by exercise, food intake, anger, excitement. Later, the similar chest pain might develop at rest.
  • Relieved by rest or GTN

Associated symptoms: n/v, diaphoresis, dyspnea

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Does the patient have all or any of the following symptom?

  • Orthopnea (dyspnea during lying back and relieved after getting up),
  • paroxysmal nocturnal dyspnea,
  • bilateral leg swelling,
  • reduced effort tolerance
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Is the patient on medicines that might trigger heartburn?   To know about the medications that might trigger heartburn, Click here
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Recommendation: Require medical referral

Rationale: Need to investigate other differential diagnosis.

Recommendation: Require medical referral

  Rationale:   
  • If heartburn doesn't respond to standard doses of these medications within two weeks, it may indicate a more serious underlying condition.
  • This could include erosive esophagitis, peptic ulcers, or even more serious conditions like esophageal cancer, which require further diagnostic evaluation.

Recommendation: Require medical referral

  Rationale:   

  • Causes of pain for other regions

    • Right Hypochondriac Region:
      • Liver: Hepatitis, abscess, tumor
      • Gallbladder: Cholecystitis (inflammation), gallstones
      • Right kidney: Kidney stones, infection (pyelonephritis)
      • Part of the pancreas
      • Part of the small intestine
    • Epigastric Region:
      • Stomach: Gastritis, ulcers, GERD
      • Duodenum (first part of the small intestine): Duodenitis, ulcers
      • Pancreas: Pancreatitis
      • Heart: Angina, myocardial infarction (referred pain)
      • Esophagus: Esophagitis
    • Left Hypochondriac Region:
      • Spleen: Splenomegaly (enlargement), rupture
      • Stomach: Gastritis, ulcers
      • Left kidney: Kidney stones, infection
      • Part of the pancreas
      • Part of the colon
    • Right Lumbar Region:
      • Ascending colon: Colitis, diverticulitis
      • Right kidney: Kidney stones, infection
      • Small intestine
    • Umbilical Region:
      • Small intestine: Enteritis, obstruction
      • Appendix: Early appendicitis
      • Aorta: Abdominal aortic aneurysm
    • Left Lumbar Region:
      • Descending colon: Colitis, diverticulitis
      • Left kidney: Kidney stones, infection
      • Small intestine
    • Right Iliac Region:
      • Appendix: Appendicitis
      • Cecum and ileum (parts of the intestines): Crohn's disease
      • Right ovary and fallopian tube (in females): Ovarian cyst, ectopic pregnancy, pelvic inflammatory disease
    • Hypogastric Region:
      • Bladder: Cystitis
      • Uterus (in females): Endometriosis, fibroids
      • Colon: Diverticulitis
      • Left Iliac Region:
      • Sigmoid colon: Diverticulitis
      • Descending colon: Ulcerative colitis
      • Left ovary and fallopian tube (in females): Ovarian cyst, ectopic pregnancy, pelvic inflammatory disease

Recommendation: Require medical referral

  Rationale:   

Cause of intense pain may be attributed to Peptic ulcer disease (PUD), Gastritis, GERD, Gastric cancer, Myocardial infarction.

Recommendation: Require medical referral

  Rationale:   

Age less than 2 years is contraindicated because

  • Difficulty in Diagnosis: It can be challenging to accurately diagnose the cause of gastrointestinal symptoms in very young children. Symptoms like crying or fussiness can be nonspecific and may indicate various issues, not just heartburn or dyspepsia.
  • Risk of Serious Conditions: Young children are more vulnerable to serious underlying medical conditions that can manifest with symptoms similar to heartburn or dyspepsia. Self-treating could delay proper diagnosis and treatment of these conditions.
  • Dosage and Safety: Administering medications to infants and very young children requires careful consideration of dosage and safety. These age groups may have different metabolic rates and organ function, increasing the risk of adverse effects from inappropriate self-treatment.
  • Lack of Clinical Evidence: There is often limited research on the safety and efficacy of heartburn medications in very young children. Therefore, healthcare professionals prefer to closely supervise their treatment.

Recommendation: Require medical referral

  Rationale:    Require further investigation as
  • Increased Risk of Serious Conditions: Older adults are at an increased risk for more serious conditions that can present with symptoms similar to heartburn and dyspepsia. These include:
    • Cardiovascular Disease: Chest pain or discomfort due to heart conditions (e.g., angina, myocardial infarction) becomes more common with age and can mimic heartburn.
    • Gastrointestinal Cancer: The risk of esophageal and stomach cancers increases with age.
    • Peptic Ulcer Disease: Complications from ulcers, such as bleeding, are more likely in older patients.
  • Complications and Atypical Presentations: They may experience complications or atypical presentations of gastrointestinal disorders, making self-diagnosis more challenging.
  • Medication Interactions: Older adults are more likely to be taking multiple medications, increasing the risk of drug interactions with over-the-counter heartburn remedies.
  • Reduced Physiological Function: Age-related changes in kidney and liver function can affect how medications are metabolized and excreted, potentially requiring dosage adjustments or making certain medications less safe.

Recommendation: Require medical referral

  Rationale:   
  • Increased Risk of Complications: Prolonged heartburn significantly increases the risk of developing more serious conditions like gastroesophageal reflux disease (GERD). GERD, in turn, can lead to complications such as erosive esophagitis, strictures (narrowing of the esophagus), Barrett's esophagus (a precancerous condition), and an increased risk of esophageal adenocarcinoma (a type of cancer).
  • Need for Diagnostic Evaluation: It indicates that there may be an underlying issue that needs proper medical diagnosis.
  • Self-treatment may mask the symptoms of a serious condition, delaying appropriate evaluation and treatment.

Recommendation: Require medical referral

  Rationale:    Differential diagnosis for angina (stable (pain during exercise; 3-5 minutes), unstable angina (pain at rest), prinzmetal angina (pain at rest), myocardial infarction (pain at rest; >20 minutes) is required

Recommendation: Require medical referral

  Rationale:    Cardiac failure should be ruled out.

Recommendation: Require medical referral

 
  Rationale:   

Reasons may be

  • Dehydration and Electrolyte Imbalance: Persistent vomiting and diarrhea can quickly lead to significant fluid and electrolyte loss which can be life-threatening, especially in children, the elderly, and individuals with underlying health conditions.
    • Sign of Severe GI Disorders: These symptoms can be indicative of serious gastrointestinal problems, including: Infections (e.g., gastroenteritis, food poisoning), Inflammatory bowel disease (e.g., Crohn's disease, ulcerative colitis), Bowel obstruction, Pancreatitis, Cholecystitis (inflammation of the gallbladder)
    • Systemic Illnesses: Nausea, vomiting, and diarrhea can also be symptoms of illnesses not directly related to the GI tract, such as: Migraines, Kidney disease, Certain metabolic disorders
  Rationale:   

Differential diagnosis for gastric ulcer should be ruled out.

  Rationale:   

These are the atypical (extraesophageal) manifestations of GERD and should be ruled out.

  Rationale:   

Suspected esophageal or gastric cancer.

  Rationale:   

Nocturnal heartburn is frequently associated with GERD, which can lead to complications like erosive esophagitis, strictures, and Barrett's esophagus.

  Rationale:   

Suspected esophageal or gastric cancer.

  Rationale:   

May be aortic aneurism, pancreatitis. Should be ruled out.

Recommendation: Require pharmacist intervention

   
  • Identify and Evaluate the Offending Medication
    • Identify Temporal relationship: Determine if the heartburn symptoms started or worsened after starting the medication.
    • Consult with a healthcare provider: It's crucial to discuss this with a doctor or pharmacist. Do NOT abruptly stop any prescription medications without professional advice, as this can have serious consequences.
  • Strategies to Reduce Medication-Induced Heartburn
    • Timing of administration: Take the medication with plenty of water.
    • Take it with or after meals (if appropriate and not contraindicated for absorption).
    • Avoid taking it right before lying down.
    • Dosage form: If possible, switch to a liquid or other less irritating formulation.
    • Alternative medications: The healthcare provider may be able to switch to an alternative medication that has a lower risk of causing heartburn.
  • Symptomatic Relief
    • Antacids, H2 Receptor Antagonists (H2RAs), Proton Pump Inhibitors (PPIs)
    • PPIs are usually reserved for more persistent or severe symptoms and are best used under medical supervision, especially for long-term use.
      • Antacids:
        • A/E: Belching and flatulence, diarrhea (Mg containing), constipation (Al/Ca containing)
          • Sodium bicarbonate antacids: may cause fluid overload, Caution in Cardiovascular disease, renal failure, cirrhosis, pregnancy, sodium-restricted diets
        • Onset: take at the onset of symptoms and relief is expected within 5 minutes. Duration of action is 20-30 min but increased when taken with food
        • Frequency: Do not use for more than 4 times and for more than 2 weeks
        • CI: 2 years
      • H2RAs:
        • A/E: headache, diarrhea, constipation, dizziness and drowsiness
        • Onset: Take 30-60 min before food prior to anticipated symptoms; relief is expected within 30-45 min. DoA is 4-10 hrs
        • Frequency:
          • Use as needed rather than scheduled basis to avoid tolerance
          • Do not use more than 2 times a day for more than 2 weeks
        • Combined with antacids: Provide quicker and sustained relief
        • CI: 12 years
      • PPIs:
        • A/E:
          • Common: Diarrhea, constipation, flatulence and headache
          • Chronic excessive use: Increased risk of infection, reduced bone mineral density, CV events, CAP, CKD, dementia, Vit. B12 deficiency, hypomagnesemia, and iron malabsorption. Many of these effects occur when use exceeds one year
        • Administration: Do not chew or crush; 30-60 min before breakfast, NICE guideline says they can be used on demand.
        • Onset and duration: Pain relief in 1-3 hours and works for 12-24 hrs. Complete relief can take 1-4 days
        • They heal ulcers but have no role in relieving symptoms of GERD
        • Avoid:
          • Self-use is limited to 14 days, no more than once every 4 months
          • If endoscopy is planned, do not take within 2 weeks (may mask pathology)
          • Use cautiously in poor renal function
        • CI: 18 years
    • Drug interactions
      • Antacids
        • itraconazole, ketoconazole, iron
          • Potential interactions: Decreased absorption due to increased pH causing impaired dissolution, disintegration or ionization
          • Management/ Preventive measures: Separate doses by at least 2 hours
        • Amphetamines
          • Potential interactions: increased absorption and decreased excretion
          • Management/ Preventive measures: Avoid concurrent use or monitor therapy
        • Rosuvastatin
          • Potential interactions: decreased absorption
          • Management/ Preventive measures: Separate doses by at least 2 hours
        • Enteric coated tablets
          • Potential interactions: increased gastric pH may cause premature breakdown of enteric coating
          • Management/ Preventive measures: Separate doses by at least 2 hours
      • CaCo3, Mg(OH)2, Al(OH)3
        • levothyroxine
          • Potential interactions: Absorption is delayed or impaired
          • Management/ Preventive measures: Separate doses by at least 6 hours
        • Tetracyclines
          • Potential interactions: decreased absorption
          • Management/ Preventive measures: Separate doses by at least 2 hours
        • Fluoroquinolones
          • Potential interactions: decreased absorption
          • Management/ Preventive measures: Take antibiotics 2 hour before or 6 hours after taking antacids
      • Na2CO3, Mg(OH)2, Al(OH)3
        • Azithromycin
          • Potential interactions: decreased absorption
          • Management/ Preventive measures: Separate doses by at least 2 hours
        • Quinidine
          • Potential interactions: increased urinary pH may decrease excretion
          • Management/ Preventive measures: Avoid concurrent use or monitor therapy
        • Salicylates
          • Potential interactions: increased urinary pH may decrease excretion
          • Management/ Preventive measures: Avoid concurrent use or monitor therapy
      • Antacids, H2RA, PPI
        • erlotinib, dosatinib, gefitinib, , other TKIs, rilpivirine, ledipasvir/sofosbuvir
          • Potential interactions: decreased absorption
          • Management/ Preventive measures: Avoid concurrent use
      • H2RAs, PPI
        • itraconazole, ketconazole, iron, CaCO3
          • Potential interactions: Decreased absorption due to increased pH causing impaired dissolution, disintegration or ionization
          • Management/ Preventive measures: Avoid concurrent use or monitor therapy
        • Citalopram
          • Potential interactions: Inhibit CYP450 2C19 leading to increased concentration and dose dependent QT prolongation
          • Management/ Preventive measures: Citalopram dose should not exceed 20 mg per day if used concurrently
      • PPIs
        • Warfarin, theophylline, tacrolimus, mycophenolate mofetil
          • Potential interactions: Inhibit CYP450 2C19 leading to increased concentration
          • Management/ Preventive measures: Avoid concurrent use
        • Digoxin
          • Potential interactions: increased absorption
          • Management/ Preventive measures: Check with prescriber
        • Methotrexate
          • Potential interactions: increased toxicity
          • Management/ Preventive measures: Avoid use of high dose methotrexate. clinically significant toxicity unlikely at lower weekly doses
      • Omeprazole, esomeprazole
        • Clopidogrel
          • Potential interactions: Inhibits conversion to its active form
          • Management/ Preventive measures: Avoid concurrent use or check with prescriber. clinically significant interaction is unlikely
        • Cilostazol, diazepam
          • Potential interactions: increased concentration of target drug
          • Management/ Preventive measures: Avoid concurrent use. lansoprazole may be a safer alternative

Recommendation: Pharmacological and non-pharmacological treatment

 

Lifestyle changes

  • Elevate the head of the bed: Using pillows or raising the head of the bed with blocks can help gravity keep stomach acid down.
  • Maintain a healthy weight: If overweight or obese, gentle exercise (isometric, running) can be beneficial.
  • Avoid tight-fitting clothing: This can put pressure on the abdomen.
  • Control emotions (anxiety, fear, worry) and stress

Dietary changes

  • Avoid or limited alcohol, smoking
  • Smaller, more frequent meals: This prevents the stomach from becoming overly full.
  • Avoid trigger foods: Fatty, fried, spicy foods, citrus fruits, chocolate, caffeine, and carbonated beverages, garlic or onions, mint, sugars, tomato/tomato juice
  • Eat slowly and chew thoroughly: This aids digestion.
  • Avoid eating close to bedtime: Allow at least 2-3 hours after eating before lying down.
  • Stay upright after eating: Avoid lying down or bending over immediately after meals.

Pharmacological instructions:

  • 1st line: calcium and magnesium containing antacid/ sucralfate/alginate

    2nd line: HHRAs (group B)/ PPIs or lansoprazole (group B, no data for breastfeeding)

  • Antacids:
    • A/E: Belching and flatulence, diarrhea (Mg containing), constipation (Al/Ca containing)
      • Sodium bicarbonate antacids: may cause fluid overload, Caution in Cardiovascular disease, renal failure, cirrhosis, pregnancy, sodium-restricted diets
    • Onset: take at the onset of symptoms and relief is expected within 5 minutes. Duration of action is 20-30 min but increased when taken with food
    • Frequency: Do not use for more than 4 times and for more than 2 weeks
    • CI: 2 years
  • H2RAs:
    • A/E: headache, diarrhea, constipation, dizziness and drowsiness
    • Onset: Take 30-60 min before food prior to anticipated symptoms; relief is expected within 30-45 min. DoA is 4-10 hrs
    • Frequency:
      • Use as needed rather than scheduled basis to avoid tolerance
      • Do not use more than 2 times a day for more than 2 weeks
    • Combined with antacids: Provide quicker and sustained relief
    • CI: 12 years
  • PPIs:
    • A/E:
      • Common: Diarrhea, constipation, flatulence and headache
      • Chronic excessive use: Increased risk of infection, reduced bone mineral density, CV events, CAP, CKD, dementia, Vit. B12 deficiency, hypomagnesemia, and iron malabsorption. Many of these effects occur when use exceeds one year
    • Administration: Do not chew or crush; 30-60 min before breakfast, NICE guideline says they can be used on demand.
    • Onset and duration: Pain relief in 1-3 hours and works for 12-24 hrs. Complete relief can take 1-4 days
    • They heal ulcers but have no role in relieving symptoms of GERD
    • Avoid:
      • Self-use is limited to 14 days, no more than once every 4 months
      • If endoscopy is planned, do not take within 2 weeks (may mask pathology)
      • Use cautiously in poor renal function
    • CI: 18 years
  • Drug interactions
    • Antacids
      • itraconazole, ketoconazole, iron
        • Potential interactions: Decreased absorption due to increased pH causing impaired dissolution, disintegration or ionization
        • Management/ Preventive measures: Separate doses by at least 2 hours
      • Amphetamines
        • Potential interactions: increased absorption and decreased excretion
        • Management/ Preventive measures: Avoid concurrent use or monitor therapy
      • Rosuvastatin
        • Potential interactions: decreased absorption
        • Management/ Preventive measures: Separate doses by at least 2 hours
      • Enteric coated tablets
        • Potential interactions: increased gastric pH may cause premature breakdown of enteric coating
        • Management/ Preventive measures: Separate doses by at least 2 hours
    • CaCo3, Mg(OH)2, Al(OH)3
      • levothyroxine
        • Potential interactions: Absorption is delayed or impaired
        • Management/ Preventive measures: Separate doses by at least 6 hours
      • Tetracyclines
        • Potential interactions: decreased absorption
        • Management/ Preventive measures: Separate doses by at least 2 hours
      • Fluoroquinolones
        • Potential interactions: decreased absorption
        • Management/ Preventive measures: Take antibiotics 2 hour before or 6 hours after taking antacids
    • Na2CO3, Mg(OH)2, Al(OH)3
      • Azithromycin
        • Potential interactions: decreased absorption
        • Management/ Preventive measures: Separate doses by at least 2 hours
      • Quinidine
        • Potential interactions: increased urinary pH may decrease excretion
        • Management/ Preventive measures: Avoid concurrent use or monitor therapy
      • Salicylates
        • Potential interactions: increased urinary pH may decrease excretion
        • Management/ Preventive measures: Avoid concurrent use or monitor therapy
    • Antacids, H2RA, PPI
      • erlotinib, dosatinib, gefitinib, , other TKIs, rilpivirine, ledipasvir/sofosbuvir
        • Potential interactions: decreased absorption
        • Management/ Preventive measures: Avoid concurrent use
    • H2RAs, PPI
      • itraconazole, ketconazole, iron, CaCO3
        • Potential interactions: Decreased absorption due to increased pH causing impaired dissolution, disintegration or ionization
        • Management/ Preventive measures: Avoid concurrent use or monitor therapy
      • Citalopram
        • Potential interactions: Inhibit CYP450 2C19 leading to increased concentration and dose dependent QT prolongation
        • Management/ Preventive measures: Citalopram dose should not exceed 20 mg per day if used concurrently
    • PPIs
      • Warfarin, theophylline, tacrolimus, mycophenolate mofetil
        • Potential interactions: Inhibit CYP450 2C19 leading to increased concentration
        • Management/ Preventive measures: Avoid concurrent use
      • Digoxin
        • Potential interactions: increased absorption
        • Management/ Preventive measures: Check with prescriber
      • Methotrexate
        • Potential interactions: increased toxicity
        • Management/ Preventive measures: Avoid use of high dose methotrexate. clinically significant toxicity unlikely at lower weekly doses
    • Omeprazole, esomeprazole
      • Clopidogrel
        • Potential interactions: Inhibits conversion to its active form
        • Management/ Preventive measures: Avoid concurrent use or check with prescriber. clinically significant interaction is unlikely
      • Cilostazol, diazepam
        • Potential interactions: increased concentration of target drug
        • Management/ Preventive measures: Avoid concurrent use. lansoprazole may be a safer alternative

Recommendation: Pharmacological and non-pharmacological treatment

 

Lifestyle changes

  • Elevate the head of the bed: Using pillows or raising the head of the bed with blocks can help gravity keep stomach acid down.
  • Maintain a healthy weight: If overweight or obese, gentle exercise (isometric, running) can be beneficial.
  • Avoid tight-fitting clothing: This can put pressure on the abdomen.
  • Control emotions (anxiety, fear, worry) and stress

Dietary changes

  • Avoid or limited alcohol, smoking
  • Smaller, more frequent meals: This prevents the stomach from becoming overly full.
  • Avoid trigger foods: Fatty, fried, spicy foods, citrus fruits, chocolate, caffeine, and carbonated beverages, garlic or onions, mint, sugars, tomato/tomato juice
  • Eat slowly and chew thoroughly: This aids digestion.
  • Avoid eating close to bedtime: Allow at least 2-3 hours after eating before lying down.
  • Stay upright after eating: Avoid lying down or bending over immediately after meals.

Pharmacological instructions:

  • First line:
    • Antacid or Alginic acid/antacid or
    • OTC low-dose H2RA or OTC high dose H2RA/antacid
 
  • Antacids:
    • A/E: Belching and flatulence, diarrhea (Mg containing), constipation (Al/Ca containing)
      • Sodium bicarbonate antacids: may cause fluid overload, Caution in Cardiovascular disease, renal failure, cirrhosis, pregnancy, sodium-restricted diets
    • Onset: take at the onset of symptoms and relief is expected within 5 minutes. Duration of action is 20-30 min but increased when taken with food
    • Frequency: Do not use for more than 4 times and for more than 2 weeks
    • CI: 2 years
  • H2RAs:
    • A/E: headache, diarrhea, constipation, dizziness and drowsiness
    • Onset: Take 30-60 min before food prior to anticipated symptoms; relief is expected within 30-45 min. DoA is 4-10 hrs
    • Frequency:
      • Use as needed rather than scheduled basis to avoid tolerance
      • Do not use more than 2 times a day for more than 2 weeks
    • Combined with antacids: Provide quicker and sustained relief
    • CI: 12 years
  • PPIs:
    • A/E:
      • Common: Diarrhea, constipation, flatulence and headache
      • Chronic excessive use: Increased risk of infection, reduced bone mineral density, CV events, CAP, CKD, dementia, Vit. B12 deficiency, hypomagnesemia, and iron malabsorption. Many of these effects occur when use exceeds one year
    • Administration: Do not chew or crush; 30-60 min before breakfast, NICE guideline says they can be used on demand.
    • Onset and duration: Pain relief in 1-3 hours and works for 12-24 hrs. Complete relief can take 1-4 days
    • They heal ulcers but have no role in relieving symptoms of GERD
    • Avoid:
      • Self-use is limited to 14 days, no more than once every 4 months
      • If endoscopy is planned, do not take within 2 weeks (may mask pathology)
      • Use cautiously in poor renal function
    • CI: 18 years
  • Drug interactions
    • Antacids
      • itraconazole, ketoconazole, iron
        • Potential interactions: Decreased absorption due to increased pH causing impaired dissolution, disintegration or ionization
        • Management/ Preventive measures: Separate doses by at least 2 hours
      • Amphetamines
        • Potential interactions: increased absorption and decreased excretion
        • Management/ Preventive measures: Avoid concurrent use or monitor therapy
      • Rosuvastatin
        • Potential interactions: decreased absorption
        • Management/ Preventive measures: Separate doses by at least 2 hours
      • Enteric coated tablets
        • Potential interactions: increased gastric pH may cause premature breakdown of enteric coating
        • Management/ Preventive measures: Separate doses by at least 2 hours
    • CaCo3, Mg(OH)2, Al(OH)3
      • levothyroxine
        • Potential interactions: Absorption is delayed or impaired
        • Management/ Preventive measures: Separate doses by at least 6 hours
      • Tetracyclines
        • Potential interactions: decreased absorption
        • Management/ Preventive measures: Separate doses by at least 2 hours
      • Fluoroquinolones
        • Potential interactions: decreased absorption
        • Management/ Preventive measures: Take antibiotics 2 hour before or 6 hours after taking antacids
    • Na2CO3, Mg(OH)2, Al(OH)3
      • Azithromycin
        • Potential interactions: decreased absorption
        • Management/ Preventive measures: Separate doses by at least 2 hours
      • Quinidine
        • Potential interactions: increased urinary pH may decrease excretion
        • Management/ Preventive measures: Avoid concurrent use or monitor therapy
      • Salicylates
        • Potential interactions: increased urinary pH may decrease excretion
        • Management/ Preventive measures: Avoid concurrent use or monitor therapy
    • Antacids, H2RA, PPI
      • erlotinib, dosatinib, gefitinib, , other TKIs, rilpivirine, ledipasvir/sofosbuvir
        • Potential interactions: decreased absorption
        • Management/ Preventive measures: Avoid concurrent use
    • H2RAs, PPI
      • itraconazole, ketconazole, iron, CaCO3
        • Potential interactions: Decreased absorption due to increased pH causing impaired dissolution, disintegration or ionization
        • Management/ Preventive measures: Avoid concurrent use or monitor therapy
      • Citalopram
        • Potential interactions: Inhibit CYP450 2C19 leading to increased concentration and dose dependent QT prolongation
        • Management/ Preventive measures: Citalopram dose should not exceed 20 mg per day if used concurrently
    • PPIs
      • Warfarin, theophylline, tacrolimus, mycophenolate mofetil
        • Potential interactions: Inhibit CYP450 2C19 leading to increased concentration
        • Management/ Preventive measures: Avoid concurrent use
      • Digoxin
        • Potential interactions: increased absorption
        • Management/ Preventive measures: Check with prescriber
      • Methotrexate
        • Potential interactions: increased toxicity
        • Management/ Preventive measures: Avoid use of high dose methotrexate. clinically significant toxicity unlikely at lower weekly doses
    • Omeprazole, esomeprazole
      • Clopidogrel
        • Potential interactions: Inhibits conversion to its active form
        • Management/ Preventive measures: Avoid concurrent use or check with prescriber. clinically significant interaction is unlikely
      • Cilostazol, diazepam
        • Potential interactions: increased concentration of target drug
        • Management/ Preventive measures: Avoid concurrent use. lansoprazole may be a safer alternative

Recommendation: Pharmacological and non-pharmacological treatment

 

Lifestyle changes

  • Elevate the head of the bed: Using pillows or raising the head of the bed with blocks can help gravity keep stomach acid down.
  • Maintain a healthy weight: If overweight or obese, gentle exercise (isometric, running) can be beneficial.
  • Avoid tight-fitting clothing: This can put pressure on the abdomen.
  • Control emotions (anxiety, fear, worry) and stress

Dietary changes

  • Avoid or limited alcohol, smoking
  • Smaller, more frequent meals: This prevents the stomach from becoming overly full.
  • Avoid trigger foods: Fatty, fried, spicy foods, citrus fruits, chocolate, caffeine, and carbonated beverages, garlic or onions, mint, sugars, tomato/tomato juice
  • Eat slowly and chew thoroughly: This aids digestion.
  • Avoid eating close to bedtime: Allow at least 2-3 hours after eating before lying down.
  • Stay upright after eating: Avoid lying down or bending over immediately after meals.

Pharmacological instructions:

  • First line:

    • OTC PPI OD * 14 days or

    • OTC H2RA as needed

 
  • Antacids:
    • A/E: Belching and flatulence, diarrhea (Mg containing), constipation (Al/Ca containing)
      • Sodium bicarbonate antacids: may cause fluid overload, Caution in Cardiovascular disease, renal failure, cirrhosis, pregnancy, sodium-restricted diets
    • Onset: take at the onset of symptoms and relief is expected within 5 minutes. Duration of action is 20-30 min but increased when taken with food
    • Frequency: Do not use for more than 4 times and for more than 2 weeks
    • CI: 2 years
  • H2RAs:
    • A/E: headache, diarrhea, constipation, dizziness and drowsiness
    • Onset: Take 30-60 min before food prior to anticipated symptoms; relief is expected within 30-45 min. DoA is 4-10 hrs
    • Frequency:
      • Use as needed rather than scheduled basis to avoid tolerance
      • Do not use more than 2 times a day for more than 2 weeks
    • Combined with antacids: Provide quicker and sustained relief
    • CI: 12 years
  • PPIs:
    • A/E:
      • Common: Diarrhea, constipation, flatulence and headache
      • Chronic excessive use: Increased risk of infection, reduced bone mineral density, CV events, CAP, CKD, dementia, Vit. B12 deficiency, hypomagnesemia, and iron malabsorption. Many of these effects occur when use exceeds one year
    • Administration: Do not chew or crush; 30-60 min before breakfast, NICE guideline says they can be used on demand.
    • Onset and duration: Pain relief in 1-3 hours and works for 12-24 hrs. Complete relief can take 1-4 days
    • They heal ulcers but have no role in relieving symptoms of GERD
    • Avoid:
      • Self-use is limited to 14 days, no more than once every 4 months
      • If endoscopy is planned, do not take within 2 weeks (may mask pathology)
      • Use cautiously in poor renal function
    • CI: 18 years
  • Drug interactions
    • Antacids
      • itraconazole, ketoconazole, iron
        • Potential interactions: Decreased absorption due to increased pH causing impaired dissolution, disintegration or ionization
        • Management/ Preventive measures: Separate doses by at least 2 hours
      • Amphetamines
        • Potential interactions: increased absorption and decreased excretion
        • Management/ Preventive measures: Avoid concurrent use or monitor therapy
      • Rosuvastatin
        • Potential interactions: decreased absorption
        • Management/ Preventive measures: Separate doses by at least 2 hours
      • Enteric coated tablets
        • Potential interactions: increased gastric pH may cause premature breakdown of enteric coating
        • Management/ Preventive measures: Separate doses by at least 2 hours
    • CaCo3, Mg(OH)2, Al(OH)3
      • levothyroxine
        • Potential interactions: Absorption is delayed or impaired
        • Management/ Preventive measures: Separate doses by at least 6 hours
      • Tetracyclines
        • Potential interactions: decreased absorption
        • Management/ Preventive measures: Separate doses by at least 2 hours
      • Fluoroquinolones
        • Potential interactions: decreased absorption
        • Management/ Preventive measures: Take antibiotics 2 hour before or 6 hours after taking antacids
    • Na2CO3, Mg(OH)2, Al(OH)3
      • Azithromycin
        • Potential interactions: decreased absorption
        • Management/ Preventive measures: Separate doses by at least 2 hours
      • Quinidine
        • Potential interactions: increased urinary pH may decrease excretion
        • Management/ Preventive measures: Avoid concurrent use or monitor therapy
      • Salicylates
        • Potential interactions: increased urinary pH may decrease excretion
        • Management/ Preventive measures: Avoid concurrent use or monitor therapy
    • Antacids, H2RA, PPI
      • erlotinib, dosatinib, gefitinib, , other TKIs, rilpivirine, ledipasvir/sofosbuvir
        • Potential interactions: decreased absorption
        • Management/ Preventive measures: Avoid concurrent use
    • H2RAs, PPI
      • itraconazole, ketconazole, iron, CaCO3
        • Potential interactions: Decreased absorption due to increased pH causing impaired dissolution, disintegration or ionization
        • Management/ Preventive measures: Avoid concurrent use or monitor therapy
      • Citalopram
        • Potential interactions: Inhibit CYP450 2C19 leading to increased concentration and dose dependent QT prolongation
        • Management/ Preventive measures: Citalopram dose should not exceed 20 mg per day if used concurrently
    • PPIs
      • Warfarin, theophylline, tacrolimus, mycophenolate mofetil
        • Potential interactions: Inhibit CYP450 2C19 leading to increased concentration
        • Management/ Preventive measures: Avoid concurrent use
      • Digoxin
        • Potential interactions: increased absorption
        • Management/ Preventive measures: Check with prescriber
      • Methotrexate
        • Potential interactions: increased toxicity
        • Management/ Preventive measures: Avoid use of high dose methotrexate. clinically significant toxicity unlikely at lower weekly doses
    • Omeprazole, esomeprazole
      • Clopidogrel
        • Potential interactions: Inhibits conversion to its active form
        • Management/ Preventive measures: Avoid concurrent use or check with prescriber. clinically significant interaction is unlikely
      • Cilostazol, diazepam
        • Potential interactions: increased concentration of target drug
        • Management/ Preventive measures: Avoid concurrent use. lansoprazole may be a safer alternative
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