t e c h talk ce t h e nat i o n a l co n t i n u i n g ed u c at i o n program fo r ph a r m a c y te c h n i c i a n s 1 CEU

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1 Continuing Education t e c h talk ce t h e nat i o n a l co n t i n u i n g ed u c at i o n program fo r ph a r m a c y te c h n i c i a n s 1 CEU free Answer online for instant results September/October 2007 CE just for technicians Tech Talk CE is the only national continuing education program for Canadian pharmacy technicians. It is independently accredited by the CE division at Rogers Publishing Ltd., publisher of Pharmacy Practice, which has been producing CE lessons for pharmacists for more than 10 years. As the role of the technician expands, use Tech Talk CE as a regular part of your learning portfolio. Note that a passing grade of 70% is required to earn the CE credit. Technicians certified by the Pharmacy Technician Certification Board of Alberta can submit CE units earned through Tech Talk CE to their certification board. Tech Talk CE is generously sponsored by Novopharm Limited. Download back issues at or Answering Options 1. Answer the lesson online and get your results instantly at 2. Use the reply card inserted with this CE lesson. Circle the answers on the card and mail in the pre-paid, self-addressed card or fax to Mayra Ramos, To pass this lesson, a grade of 70% (7 out of 10) is required. If you pass, you will receive 1 CEU. You will be advised of your results in a letter from Tech Talk. Please allow 8 to 12 weeks. Please note: Tech Talk CE is not accredited by the Canadian Council for Continuing Education in Pharmacy (CCCEP). CE Faculty CE Coordinator: Margaret Woodruff, R.Ph, B.Sc. Phm., MBA Humber College Clinical Editor: Lu-Ann Murdoch, B.Sc.Phm. Author: Mary Nelson, B.Sc.Phm, RPh Reviewer: Christine McCracken Pharmacy technician; Neepawa District Health Centre. Manitoba OTC Heartburn/ GERD By Mary Nelson,, BScPhm, RPh Statement of objectives Upon completion of this lesson, the pharmacy technician should be able to: 1. Explain the symptoms of gastroesophageal reflux disease (GERD) 2. Identify at least eight risk factors for GERD 3. List the usual over-the-counter (OTC) products used to treat patients with mild symptoms of GERD 4. Identify at least four warning signs requiring a pharmacist and/or physician intervention Overview About 20% of adults experience at least weekly episodes of gastroesophageal reflux disease (GERD), more commonly known as acid reflux or heartburn, although only one-quarter will consult their physician. 1 This offers the dispensary team opportunities to assist patients in selecting the most appropriate therapeutic management, and provide counselling and referral as required. GERD affects people of all ages, with equal frequency in men and women. 2 Symptoms include a burning pain behind the breastbone, which may rise into the chest, throat and possibly face. 3 It may be accompanied by regurgitation of stomach contents into the mouth and/ or excessive salivation. How the Esophagus Works Food passes from the mouth to the stomach via waves of muscular contractions of the esophagus (a tube that connects the mouth to the stomach), called peristalsis. The lower esophageal sphincter (LES), located where the esophagus joins the stomach, opens and closes to control the passage of food from the esophagus into the stomach. If it does not function properly, acid contents of the stomach are allowed to reflux back into the esophagus. Special cells lining the stomach protect it from its own acids. However, the esophagus lacks a similar protective lining, so the acidic stomach contents that reflux back An educational service for Canadian pharmacy technicians, brought to you by Novopharm Win a Sony PSP prize package! (Value $430) Find out how on page 4. into the esophagus can cause pain, inflammation (esophagitis) and possibly other damage. The degree of inflammation depends on the acidity of the stomach contents, the volume of stomach acid in the esophagus, and the patient s ability to clear the regurgitated fluid. Symptoms Heartburn typically occurs minutes after meals and can be aggravated by lying down, wearing tight clothing or bending over. 1 The severity of symptoms does not correlate with the degree of tissue damage, and some patients, despite severe esophagitis, have only mild symptoms. Patients may complain of regurgitation; the spontaneous reflux of sour or bitter gastric contents into the mouth. One-third of patients may experience dysphagia (difficulty swallowing) due to erosive esophagitis, abnormal esophageal peristalsis, or the development of an esophageal stricture (narrowing of a portion of the esophagus). 1 Many patients present with symptoms that may be caused and/or related to GERD, but are considered to be atypical symptoms; these may include asthma, chronic cough, chronic laryngitis, sore throat and non-cardiac chest pain. 1 Risk Factors Factors that increase the risk of GERD include: 2 foods that lower LES pressure (high fat content, yellow onions, chocolate, peppermint)

2 t e c h talk c e pregnancy (progestational hormones decrease LES pressure) foods that irritate the esophagus (citrus fruits, tomato products, spicy foods, coffee) smoking and alcohol sliding hiatal hernia where the junction between the esophagus and the stomach and also a portion of the stomach (which are both normally below the diaphragm) protrude above it tend to be constipating, while magnesium has a laxative effect, so most patients may prefer combination products, which tend to balance these two adverse effects. Since the kidney must eliminate excessive magnesium, magnesium-containing products should be used cautiously in patients with renal failure. Gaviscon contains alginate (which provides a protective barrier in addition to its antacid effect 5 ), and therefore it decreases symptoms be given a trial of a once-daily PPI such as omeprazole (Losec) or rabeprazole (Pariet) 20 mg, lansoprazole (Prevacid) 30 mg, esomeprazole (Nexium) or pantoprazole (Pantoloc) 40 mg. Omeprazole and pantoprazole may be taken with food, and lansoprazole should be taken on an empty stomach. 6 Patients who experience symptomatic relief with either an H 2 -blocker or PPI should consider stopping therapy after eight to twelve delayed gastric emptying (stomach con- even in the standing position. weeks. If patients experience a relapse of their Continuing Education tents do not empty into the intestine at the normal rate) chronic belching; air swallowing drugs that lower LES pressure (for example: anticholinergics [e.g., atropine, benztropine, ipratropium]; tricyclic antidepressants [e.g., amitriptyline, clomipramine, doxepin]; calcium channel blockers [e.g., amlodipine, diltiazem, verapamil]; alpha adrenergic agents [e.g. doxazosin, tamsulosin, terazosin]; beta blockers [e.g. atenolol, Histamine-2 blockers (H 2 -blockers) reversibly and competitively inhibit histamine-2 receptors in the stomach to inhibit both fasting and nocturnal gastric acid secretion. 5,6 Products available over the counter in Canada include ranitidine (Zantac) and famotidine (Pepcid AC) and their generic equivalents. When taken for active heartburn there is usually a delay in effect for at least 30 minutes, so antacids are usually preferred for their more immediate action. However, the H 2 -blockers provide heartburn relief for up to symptoms, many can be managed with intermittent (predetermined short courses, usually 2-8 weeks) or on demand therapy (start PPI when symptoms arise and then discontinue once symptoms resolve) rather than continuous maintenance treatment. 7 Since both H 2 -blockers and PPIs inhibit stimulated gastric acid secretion, they might be best taken minutes before meals (usually breakfast for once-daily regimens; breakfast and supper for twice-daily bisoprolol, metoprolol]) eight hours and are preferred when a longer regimens). Patients experiencing noctur- drugs that can irritate the esophagus (for duration of action is required. nal symptoms may benefit from taking the example: ascorbic acid; bisphosphonates Patients should be advised to take an second dose at bedtime. Although a bedtime [e.g., alendronate, risedronate]; doxycycline; H 2 -blocker prior to a meal known to provoke dose of H 2 -blocker in patients with GERD potassium chloride; quinidine) heartburn if those foods cannot be avoided, taking twice-daily PPIs may increase gastric chest trauma such as broken ribs thereby reducing symptoms. When experiencing ph, there is no clinical evidence to support obesity (body mass index [BMI] > 30) active heartburn, a combination of antacid and this. 7 Due to potential reduced absorption Non-Drug Management H 2 -blocker would provide both immediate and prolonged effects and may be preferred. by concomitant use of antacids, spacing the doses of antacid with cimetidine and ranitidine GERD is a lifelong disease requiring lifestyle modifications and possibly medical interven- Moderate Symptoms is recommended, although there is not a similar concern with famotidine and nizatadine or with tion. 1 Patients should be advised not to lie Patients experiencing acid reflux daily or any of the PPIs. 6 down within three hours after eating, which is the period of greatest reflux. 1,4 Elevating several times per week, with uncomplicated disease [i.e., those without any of the warn- Severe Symptoms the head of the bed on 6-inch blocks or using ing signs discussed below] should be referred Initial PPI therapy is recommended for any a foam wedge under the head portion of the to a physician for treatment. The goal of patient with severe symptoms or endoscopy- mattress, especially for people with nocturnal therapy is to raise the intragastric ph > 4 dur- proven erosions or strictures. Once-daily PPIs symptoms, may enhance esophageal clearance. ing the time when reflux is likely to occur. 4 (in the doses mentioned above) provide symp- Patients should be advised to avoid the foods Ranitidine or nizatadine 150 mg, famoti- tom relief and esophageal healing in over 80% and lifestyle factors mentioned above that can dine 20 mg or cimetidine 600 mg twice daily of patients; this improves to 95% with twice- aggravate GERD symptoms, or specific foods are equally effective and provide improve- daily dosing. 1 In comparison, standard doses they have identified as being a problem for ment in up to two-thirds of patients with of H 2 -blockers provide relief in only 50% and them. Reduction of meal size, no snacks within moderate disease. Since cimetidine has many therefore are not recommended for patients three hours of bedtime, avoiding bending after potential drug interactions, it has lost favour with severe or erosive disease. eating or tight-fitting clothing, and weight loss to the other agents. There appears to be little difference in effi- if more than 20% over ideal body weight may Proton pump inhibitors (PPIs) irreversibly cacy or adverse effects among the currently also be helpful. inhibit the proton pump in the stomach, there- available PPIs. 1,7 Although esomeprazole (the Mild, Intermittent Symptoms by blocking the final step in both basal (baseline) and stimulated gastric acid secretion. 5, 6 S-isomer of omeprazole) may have a slightly greater effect on reducing acidity or increasing Rapid relief of occasional heartburn is usually They are more effective than H 2 -blockers and gastric ph, the clinical significance has not managed with antacid therapy (which neutral- are usually given once daily; however, they been determined, and choice of PPI is there- izes the gastric acid 5 ) due to the rapid onset of are significantly more expensive so they are fore based on cost and patient tolerance. 7 action; however, all antacids have a relatively not routinely used in all patients with moderate The initial course of PPI therapy is eight to short duration of action (less than 2 hours). disease. Patients who do not respond to six twelve weeks. Symptom relapse occurs in 80% Aluminum and calcium containing antacids weeks of standard-strength H 2 -blockers should of patients within one year of stopping the PPI, 2 tech talk September/october 2007

3 usually within the first three months. 1 Chronic therapy at the lowest effective dose is therefore recommended for most patients, including those with severe erosive esophagitis, Barrett s esophagus or peptic stricture. Prolonged PPI therapy may result in hypergastrinemia and the potential for impaired calcium absorption or vitamin B 12 deficiency. Unresponsive Disease dysphagia (difficulty swallowing) odynophagia (sharp substernal pain on swallowing) atypical chest pain occult or overt blood in the stool iron deficiency anemia extraesophageal symptoms (e.g., unexplained chronic cough, laryngitis or sore throat) weight loss (> 5%) Lippincott Williams & Wilkins, Disorders of the esophagus. In: Berkow R, Beers MH, Fletcher AJ, editors. The Merck Manual of Medical Information Home Edition. Whitehouse Station NJ: Merck Research Laboratories, Shaffer EA. Gastroesophageal reflux disease. In: Gray J, editor. Therapeutic Choices, 4th ed. Ottawa ON: Canadian Pharmacists Association, Treatment of gastroesophageal reflux disease (GERD). UBC Therapeutics Initiative. Therapeutics Letter 1994, Issue Cadario BJ, Leathem AM, editors. Drug information t e c h talk c e In the 5% of patients who do not respond to twice-daily PPI therapy, endoscopy is recommended. Active erosive esophagitis is indicative of insufficient acid suppression and can usually be managed with higher PPI doses (e.g., omeprazole 40 mg twice daily). Zollinger- Ellison syndrome (hypersecretion of gastric persistent vomiting Any patient presenting to a technician with these symptoms should be referred to the pharmacist for counselling and further referral as required. Pharmacy Technician s Role reference. 5th ed. Vancouver: The BC Drug and Poison Information Centre, Armstrong D, Marshall JK, Chiba N, et al. Canadian consensus conference on the management of gastroesophageal reflux disease in adults-update Can J Gastroenterol 2005; 19(10): acid), drug-induced esophagitis, resistance to Pharmacy technicians provide a valuable sup- PPI therapy (genetic rapid metabolizer or gastric portive role for pharmacists in the patient care acid hypersecretor), or non-adherence may be process. By being familiar with medications and responsible for truly refractory cases. 1 lifestyle issues that may increase a patient s risk for developing acid reflux, technicians can help Complications the pharmacist to identify patients who may Barrett s esophagus can occur in up to 10% of benefit from OTC GERD products. As first- patients with chronic reflux. 1 Chronic reflux- line members of the pharmacy team, techni- induced injury to the esophageal squamous cians can also identify patients who are regularly epithelium results in the development of spe- self-selecting antacids and OTC H 2 -blockers, cialized intestinal precancerous cells. Most and suggest they discuss their symptoms and patients with Barrett s esophagus do not expe- management with the pharmacist, who in turn rience any additional symptoms and therefore might suggest a physician referral. are unaware of their condition. Only 10% of patients with Barrett s esophagus seek medical Summary attention for complications including stricture Although many people have experienced an formation, ulceration and bleeding, or esophageal occasional episode of heartburn after a large or carcinoma. spicy meal, for 20% of the population this occurs Ten per cent of GERD patients may expe- at least weekly. Only one-quarter of these people rience stricture formation resulting in gradual will bring this to their physician s attention and development (over months to years) of difficulty many will attempt to resolve their symptoms in swallowing solid food. 1 These strictures may by self-selecting OTC products. The pharma- require periodic dilatation despite maintenance cist and pharmacy technician can be a valuable doses of a PPI. There is often a reduction in resource in helping patients to understand the heartburn as the stricture progresses as it acts as a pathophysiology of their condition as well as the barrier to reflux. Endoscopy with biopsy is man- most effective management, including lifestyle datory in all cases to rule out esophageal carci- modifications, identifying drug therapy that noma. The risk of cancer increases with the may be aggravating symptoms, monitoring for severity, frequency and duration of GERD side effects, choosing OTC products or suggest- symptoms. 7 ing a physician referral when required. Warning Signs Initial medical therapy for GERD is usually guided by the presence of symptoms. Endoscopy References: is reserved for those patients who do not respond to empiric therapy and those patients with symptoms suggesting complicated disease. Symptoms of complicated disease are 1. McQuaid KR, Gastroesophageal reflux disease. In: McPhee SJ, Papadakis MA, Tierney LM Jr, editors. Current Medical Diagnosis and Treatment 46th edition. New York NY: McGraw Hill Medical, warning signs that could indicate more serious 2. Gastroesophageal reflux disease. In: Dambro MR, disease. These symptoms include: 4 Griffith s 5 Minute Consult Philadelphia PA: tech talk September/october

4 t e c h talk c e Continuing Education Questions Please select the best answer for each question or answer online at for instant results. 1. Heartburn: a) Causes a salty taste in the mouth b) Occurs when acidic stomach contents irritate the lining of the lower esophagus c) Occurs when a person doesn t chew their food properly d) Is more common in men than women e) Is more common in older people 2. Symptoms of heartburn typically: a) Occur right after someone eats a spicy meal b) Can be improved by lying down c) Correlate closely with the degree of tissue damage d) Occur 30 to 60 minutes after a meal e) Include burning pain in the throat 3. The best diagnostic procedure to determine the extent of tissue damage is: a) Chest X-ray b) Ambulatory Holter monitor c) Upper endoscopy with biopsy d) Stool samples for occult blood e) None of the above 4. Barrett s esophagus a) Occurs in 20% of patients b) Causes severe heartburn in most patients c) Can lead to esophageal cancer d) Is the most common reason for patients to seek medical advice e) Is nothing to be concerned about 5. Drugs that can aggravate GERD include: a) Amlodipine b) Risedronate c) Terazosin d) All of the above e) None of the above 6. For patients complaining of heartburn, the pharmacist could suggest: a) Having a glass of red wine with dinner b) Elevating the foot of the bed c) Drinking lots of water d) Sucking on peppermint candies e) Quitting smoking 7. The best advice for a patient with heartburn one hour after eating pizza is: a) Avoid eating pizza b) Use Pepcid Complete c) Use Gaviscon d) a) and b) e) a) and c) 8. In patients experiencing severe GERD symptoms: a) There is no benefit to increasing the dose of PPI to twice daily b) Switching from an H 2 blocker to a PPI can almost double the improvement rate in symptoms c) The initial course of therapy is 8 to 12 weeks d) a) and c) e) b) and c) 9. In patients experiencing GERD symptoms several times per week, they should be referred to their physician who would most likely prescribe: a) Maalox after every meal b) Cimetidine 400 mg twice daily c) Gaviscon whenever symptoms occur d) Famotidine 20 mg twice daily e) Ranitidine 150 mg with breakfast 10. Patients with difficulty swallowing: a) Should be referred to a physician for endoscopy b) Should only be treated with Nexium c) May respond to any of the available PPIs d) a) and b) e) a) and c) For information about CE marking, please contact Mayra Ramos at (416) or fax (416) or mayra.ramos@rci.rogers.com. All other inquiries about Tech Talk CE should be directed to Tanya Stuart at (416) or tanya.stuart@pharmacygroup.rogers.com Hey Techs! Do you do Tech Talk CE? Finish a Tech Talk CE lesson and refer a colleague to do it too for a chance to win 1 of 3 great prizes. Up for grabs: 2 Sony Playstation Portable (PSP) prize packages 1 Apple ipod Nano Click on to access over 20 Tech Talk CE lessons. Go to to refer a colleague, or simply complete the fields below and fax back your referral to Referral name Referral address Referral or phone # Your name, and phone # Name of lesson completed Contest Closes: September 30, 2007 To enter, you must be employed as a pharmacy technician and be a Canadian resident over the age of majority. Entry form and Full Rules at techcontest. Odds of winning depend on number of eligible entries received. Mathematical skill-testing question must be correctly answered to win. No purchase necessary. TECH t e c h talk Tech Talk CE is proudly sponsored by: TELL TECH tech talkce 4 tech talk September/october 2007

5 tech talkce SEPTEMBER/OCTOBER 2007 Presented by: Sponsored by: OTC Heartburn/GERD 1 CEU 1. a b c d e 2. a b c d e 3. a b c d e 4. a b c d e 5. a b c d e 6. a b c d e 7. a b c d e 8. a b c d e 9. a b c d e 10. a b c d e First Name Last Name Pharmacy Name Home Address City Province Postal Code Telephone Fax Online answering now available! Type of practice Full-time technician Drug chain or franchise Grocery store pharmacy Part-time technician Banner Hospital pharmacy Independent Other (specify): Are you a certified technician? Mass merchandiser Yes No Please help ensure this program continues to be useful to you by answering these questions. 1. Do you now feel more informed about managing OTC Heartburn/GERD? Yes No 2. Was the information in this lesson relevant to you as a technician? Yes No 3. Will you be able to incorporate the information from this lesson into your job as a technician? Yes No N/A 4. Was the information in this lesson... Too basic Appropriate Too difficult 5. How satisfied overall are you with this lesson? Very Somewhat Not at all 6. What topic would you like to see covered in a future issue? ANSWERING OPTIONS: 1. Answer ONLINE for immediate results at 2. MAIL or FAX this reply card to Mayra Ramos at (Please allow 8-12 weeks for notification of score) Pharmacy Practice and Novopharm Limited recognize and appreciate the importance of responsible use of information collected through their continuing education program. If you do not want to receive information or contact from Novopharm regarding products or programs please indicate below and Pharmacy Practice will honour your preference. [ ] No, I do not want to receive information from Novopharm Limited TT_BRC_0907_ENG.indd 1 8/16/07 3:38:11 PM

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Heartburn Overview. Causes & Risk Factors

Heartburn Overview. Causes & Risk Factors Return to Web version Heartburn Overview What is heartburn? Despite its name, heartburn doesn't affect the heart. Heartburn is a burning feeling in the lower chest, along with a sour or bitter taste in