For more information:

1. For more information: NHS Choices http://www.nhs.uk/conditions/indigestion/Pages/Introduction.asp INDIGESTION (DYSPEPSIA) AND HEARTBURN (ACID REFLUX) Symptoms: A gnawing or burning stomach pain, bloating, heartburn (acid reflux), upsetstomach, vomiting and belching which often results from overeating, eating high fat meals or being overweight. These symptoms should normally resolve within one or two weeks. Common causes include acid reflux , inflammation, medicines, infection with H. pylori, or a hiatus hernia. Rarely, a stomach ulcer or cancer of the stomach or gullet may be responsible. Always follow WWHAM protocol and advise to read PIL before taking any medicine Pharmacist should refer to a clinician if the patient presents with any of the following Red Flags • Significant interactions/warnings • Omeprazole and Pantoprazole • Anti-coagulants/platelet drugs – enhances blood thinning • Phenytoin – enhances effects of phenytoin • Antacids • These should not be taken at the same time (2hrs) as other drugs since they may impair the absorption of other drugs • Please refer to the British National Formulary and individual product packaging for cautions and contra- indications • Red flags • Pain/ other stomach/ chest symptoms - Severe, persistent pain (longer than three weeks), worsening and unexplained pain in the upper abdomen, particularly if occurring with other symptoms, such as pain in the chest, pain radiating through the back to the arms, breathlessness, sweating, feeling sick and vomiting • Vomiting blood - or dark lumps (like coffee grounds) • Dark stools - Stool colour has become very dark (looking like tar) – N.B. iron tablets can also cause this and need to be ruled out • Feeling faint • NSAIDs – regular long term use of prescribed NSAIDs • Unexplained fever, night sweats • Swelling or mass in the upper abdomen • Unexplained weight loss • Recurrent symptoms • Proven anaemia • Difficulty in swallowing • Caution: • Pregnant or breastfeeding • Age – Particular care should be taken in those aged 55 years and over • Self care advice • Smoking - Reduce or stop smoking, which may help improve symptoms. • Avoiding NSAID/aspirin-like drugs - If taking OTC anti-inflammatory pain killers (consult GP if taking prescribed NSAIDs) • Avoid stress • Diet - Eat small regular meals and reduce the amount of fatty or spicy foods in the diet • Alcohol and caffeine - Reduce caffeine and alcohol intake • At bedtime - If experiencing indigestion symptoms at night, avoid eating for three to four hours before going to bed as there is an increased risk that acid in the stomach will be forced up into the oesophagus while they are lying down • Healthy weight - Being overweight puts more pressure on the stomach, making it easier for stomach acid to be pushed back up into the oesophagus

2. Treatment option ONE Always follow WWHAM protocol and advise to read PIL before taking any medicine Intermittent symptoms Antacid containing product • These products are best taken • After meals • Before bedtime • These products can be used up to its maximum dose for up to one week, please see the individual packs for guidance on dosage instructions. If symptoms do not improve or the symptoms quickly return after the effects of the product have worn off, then recommend products for persistent symptoms Alginate containing product Antacid and alginate combination product Antacids work by altering the acidity of the stomach contents. It decreases the acidity which help relieve the pain and discomfort of the heartburn and indigestion. Alginates work by forming a raft (thick layer) on top of the stomach contents soon after it had made contact with the stomach acid. The raft acts as a strong physical barrier and helps keep all the components of the stomach contents in the stomach where they work, not letting them seep back up into the oesophagus where they hurt. Proton pump inhibitors E.g.Pantoprazole, Omeprazole Take ONE Pantoprazole 20mg tablets per day. It might be necessary to take these tablets for 2-3 consecutive days to see any improvement of symptoms. Once symptoms have resolved treatment should be discontinued. If symptoms do not improve within TWO weeks of continuous treatment refer to the pharmacist. Take up to TWO Omeprazole 10mg tablets per day for up to TWO weeks or until symptoms have resolved. It might be necessary to take these tablets for 2-3 consecutive days to see any improvement of symptoms. Once symptoms have resolved treatment should be discontinued. If symptoms do not improve within TWO weeks of continuous treatment refer to the pharmacist. Persistent symptoms Take ONE Ranitidine 75mg tablet as soon as symptoms occur. If symptoms persist for more than one hour or return, one more tablet may be administered up to its maximum dose. For prevention of symptoms associated with consuming food and drink, take ONE tablet half to one hour before eating or drinking. If symptoms do not improve within TWO weeks of continuous treatment refer to the pharmacist. H2 antagonists E.g. Ranitidine Proton pump inhibitors work by blocking the release of acid in the stomach. They are the only licensed preparations of this type of medication that are available OTC and are only suitable for adults ages 18 and over. H2 antagonist work by reducing stomach acid indirectly by preventing the activation of acid production. It can relieve heartburn associated with acid indigestion, and it can relieve heartburn fast. This medication may only used in people aged 16 and over.

3. Follow-up Treatment – Pharmacist only Always follow WWHAM protocol and advise to read PIL before taking any medicine Intermittent symptoms Antacid containing product • These products are best taken • After meals • Before bedtime • These products can be used up to its maximum dose for up to a WEEK, please see the individual packs for guidance on dosage instructions. If symptoms do not improve or the symptoms quickly return after the effects of the product have worn off, then recommend products for persistent symptoms Alginate containing product Antacid and alginate combination product Antacids work by altering the acidity of the stomach contents. They decreases the acidity which help relieve the pain and discomfort of the heartburn and indigestion. Alginates work by forming a raft (thick layer) on top of the stomach contents soon after making contact with the stomach acid. The raft acts as a strong physical barrier and helps keep all the components of the stomach contents in the stomach, and not letting them seep back up into the oesophagus where they hurt. Persistent symptoms Proton pump inhibitors E.g.Pantoprazole, Omeprazole Take ONE Pantoprazole 20mg tablets per day. It might be necessary to take these tablets for 2-3 consecutive days to see any improvement of symptoms. Once symptoms have resolved treatment should be discontinued. Take up to TWO Omeprazole 10mg tablets per day for up to TWO weeks or until symptoms have resolved. It might be necessary to take these tablets for 2-3 consecutive days to see any improvement of symptoms. Once symptoms have resolved treatment should be discontinued. For BOTH treatments if symptoms have improved but not fully resolved within TWO weeks, continue treatment for a further TWO weeks and add Gaviscon suspension for occasional breakthrough symptoms. If symptoms do not improve within FOUR weeks of treatment refer to the GP Take ONE Ranitidine 75mg tablet as soon as symptoms occur. If symptoms persist for more than one hour or return, one more tablet may be administered up to its maximum dose. For prevention of symptoms associated with consuming food and drink, take ONE tablet half to one hour before eating or drinking. If symptoms have improved but not fully resolved within TWO weeks, continue treatment for a further TWO weeks and add Gaviscon suspension for occasional breakthrough symptoms. If symptoms do not improve within FOUR weeks of treatment refer to the GP H2 antagonists E.g. Ranitidine Proton pump inhibitors work by blocking the release of acid from the stomach. They are the only licensed preparations of this type of medication that are available OTC and are only suitable for adults ages 18 and over. H2 antagonists work by reducing stomach acid indirectly by preventing the activation of acid production. Can relieve heartburn associated with acid indigestion, and fast. This medication may only used in people aged 16 and over.