Antacids
Antacids contain one or more of the following alkaline salts - sodium bicarbonate, aluminium hydroxide, magnesium carbonate or calcium carbonate (e.g. Tums, Original Andrews Salts, Rennie, Phillips’ Milk of Magnesia, Asilone and Setlers Antacid).

They work by neutralising the excess acid in the stomach. While they are an obvious treatment choice for indigestion, they can also be of benefit in heartburn. Antacids tend to provide fast relief from symptoms but are short-acting as they do not stop the secretion of stomach acid but neutralise the acid present.

Antacids are convenient as they are available as tablets, chewable tablets, effervescent granules or powders and suspensions. 

They are also available in combination with other medicines, such as H₂-receptor antagonists, to give enhanced relief.  These products can be used to treat mild or infrequent episodes of heartburn and indigestion.  Antacids are best given when the symptoms have occurred or are expected, usually between meals and at bedtime.

However, they can interact with a number of prescribed drugs, including antibiotics, anticonvulsants, antifungals, antipsychotics and antirheumatics and should not be taken at the same time as other medication. Antacids high in sodium are best avoided by anyone on a salt-restricted diet. Magnesium salts can cause diarrhoea and aluminium salts can cause constipation. Using the WWHAM* questions will allow you to investigate these issues with your patient and if in doubt the check with the pharmacist.

 <PRACTICE POINT>
Look at the heartburn and indigestion products stocked by your pharmacy and note which ones contain:
Aluminium hydroxide
Calcium carbonate
Sodium bicarbonate
Magnesium carbonate
Also check the different types of formulations available.


Alginates
Products containing sodium alginate (e.g. Gaviscon, Gaviscon Double Action) are sometimes called ‘rafting agents’ because they form a floating raft or layer on top of the stomach contents. When heartburn occurs and the stomach’s contents are forced back up into the oesophagus, the raft travels upwards first. It then coats the delicate surface of the oesophagus, preventing the stomach acid causing irritation to the delicate tissues underneath.  These products also contain an antacid which has the additional benefit of neutralising the stomach’s acid.
These products can be used to treat the symptoms of mild or infrequent heartburn and indigestion and are best taken after meals and at bedtime.
Some preparations have a high sodium content and are therefore inappropriate for patients on a salt-restricted diet.

H₂-receptor antagonists
Examples include ranitidine (e.g. Zantac 75, Zantac 75 Relief) and famotidine (e.g. Pepcid AC) are H₂- receptor antagonist available OTC (at a lower dose than preparations available on prescription). These work by suppressing the secretion of acid in the stomach.

H₂-receptor antagonists can be used to treat customers who are suffering from heartburn and indigestion more than 2 times per week and want longer lasting action other than antacids or alginates.  These products are licensed for the short-term (up to two weeks) symptomatic relief of heartburn and acid indigestion. The tablets can give up to 12 hours’ relief. They should not be sold to patients with hepatic or renal impairment, or to pregnant or breast feeding women or those under the age of 16 years. These products should not be given to patients who are allergic to the drug or any of the ingredients of the product. Do not give to patients who suffer from a rare condition called porphyria.  If the customer is taking other medication are pregnant or breastfeeding, have unintended weight loss, is middle aged or older with new or recently changed indigestion symptoms then they should be referred to the pharmacist for further advice.   <PRACTICE POINT>
Discuss with your colleagues  which types of customers requesting H₂- receptor antagonists should be referred to them for further advice.       

Proton pump inhibitors (PPIs)
Omeprazole (e.g. Zanprol) is a proton pump inhibitor (PPI). It is only activated when it reaches its site of action - the acid-producing cells in the lining of the stomach. Once present and activated, omeprazole inhibits the proton pump in these cells and suppresses the final stage of acid secretion in the stomach.  These products should be recommended to customers for relief of recurrent symptoms and require a long lasting treatment giving 24 hour gastric suppression and  symptom relief.

It is important to point out to customers that PPIs do not provide fast relief of symptoms - omeprazole takes three to four days to reach maximum effectiveness. They may therefore want to take antacids initially alongside omeprazole. Following treatment, omeprazole can give weeks of remission from recurrent attacks (see e-learning module for more information about omeprazole). They should not be sold to patients with hepatic or renal impairment, or to pregnant or breast feeding women or those under the age of 18 years.  PPIs can interact with other prescribed medication so customers taking any other medication should be referred to the pharmacist for further advice.

<PRACTICE POINT 1>
Look the information on the Zanprol packaging and note the following points: 

• Who it is suitable for 
• Recommended dosages
• How to take the tablets
• Any cautions.

<PRACTICE POINT 2 >
Think about the advice and OTC treatments(if any) you would give to the following customers:

1. Pregnant lady at the end of her pregnancy complaining of a sour taste in her mouth and a feeling the food is coming back into her mouth
2. Young man who has eaten a curry and drank too much beer the previous evening
3. A very busy gentleman who admits he misses meals when he is stressed at work in  the city.  He wants to take a tablet or capsule that will give maximum relief.
   

*  W - Who is the medicine for?
   W - What is the medicine for?
   H - How long have the symptoms been present?
   A - Action already taken?
   M - Medicines taken for other reasons, prescribed or otherwise?

(Also see treatment algorithm in the e-learning module)