OTC Management
ABDOMINAL PAIN
in the pharmacy
Patients often come into the pharmacy complaining of abdominal
pain. The cause can vary from heartburn to food intolerance to irritable bowel syndrome. It is important to identify the possible cause of
the problem so that you, the pharmacist’s assistant, can suggest an
appropriate treatment or refer the patient appropriately for further
medical attention.
Joy Zuccaroli, BPharm
Jacqueline van Schoor, MPharm
Amayeza Info Centre
1. Heartburn
SA Pharmacist’s Assistant [ Autumn 2007 ]
Heartburn affects most people at some
stage of their lives. Whether due to
poor diet or obesity, heartburn seems
to be reaching epidemic proportions.
It occurs when hydrochloric acid from
the stomach moves past the oesophageal valve and up into the oesophagus (gullet), burning the sensitive tissue of the oesophagus and causing
pain. Symptoms may include:
• A burning sensation in the chest
• Belching (burping)
• Bloating
• Bad taste in the mouth
• Problems with swallowing
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The possible cause of heartburn can
vary from eating spicy food or lying
down after eating a heavy meal to more
sinister causes, such as an ulcer or cancer. Any patient who presents with
symptoms of heartburn and with the
following should be referred to the
doctor:
• Pregnant women
• Children under 12 years old
• New onset of symptoms in a patient who is over the age of 45 years
• Symptoms of weight loss or difficulty in swallowing
• Patients suffering from kidney
problems – because of contra-in-
dications with sodium-containing
antacids
• Otherwise healthy individuals who
develop severe symptoms such as
vomiting blood or report the presence of blood or mucus in the
stools
• Persistent or recurrent symptoms
despite appropriate treatment
Remember to check whether the patient is taking any other medication so
as to avoid potential drug interactions!
Non-drug measures that may be recommended to manage symptoms of
heartburn could include:
• Eating smaller and more frequent
meals
• Not wearing tight clothes
• Avoiding smoking, drinking alcohol
or caffeine-containing drinks such
as coffee and colas
• Avoiding spicy and fatty foods, including chocolate
• Losing weight, if overweight
• Regular exercise
If patients suffer from heartburn at
night, then using more pillows in order to sleep in a more upright position may help.
The high prevalence of heartburn has
led to the substantial use of over-thecounter medicines. The medicines that
may be recommended to manage
heartburn include antacids, especially
antacids in liquid form due to the faster
relief of symptoms, alginates, an histamine-two (H2) antagonist or a proton pump inhibitor.
• Antacids e.g. Rennie®
Whereas we once thought antacids
acted in the stomach by reducing the
pH in the stomach, we now know that
antacids largely work within the oesophagus to quickly raise the oesophageal pH and neutralise oesophageal
acid for up to 90 minutes after dosing.
The change in gastric pH is often quite
small.
There are few well-controlled studies
testing antacids for heartburn. Nonetheless, studies have shown that antacids are effective in relieving heartburn.
The on-demand use of antacids (up to
twice daily) has also been shown to be
effective for the complete relief of
spontaneous heartburn.
Overall, antacids provide fast relief of
heartburn. Their limitations lie in their
relatively short duration of action and
their ineffectiveness in preventing
heartburn. The average heartburn epi-
OTC Management
ABDOMINAL PAIN
member that patients must see a doctor if symptoms persist for longer than
two weeks, as these treatments are short
term unless prescribed by a doctor.
sode lasts 90 minutes. (Duration of
action of antacids, like Rennie®, lasts
80 minutes and the onset of action is
5 minutes.) Patients with high blood
pressure or kidney problems are best
advised to avoid antacids with a high
sodium (salt) content e.g. sodium bicarbonate containing antacids. Aluminium containing antacids e.g. aluminium hydroxide should not be used
by patients with kidney damage. Calcium or magnesium containing antacids should not be prescribed for patients taking tetracycline antibiotics as
the calcium or magnesium can bind to
the antibiotic and make it ineffective.
SA Pharmacist’s Assistant [ Autumn 2007 ]
• Alginates e.g. Gaviscon®
Alginates work by reacting with saliva
and gastric acid to produce a gel which
floats on top of the stomach contents,
preventing reflux of stomach contents.
Alginic acid in combination with an
antacid has been shown to relieve mealinduced heartburn within 15 minutes.
The alginates can safely be used in pregnancy. Alginic acid preparations offer
little or no benefit to patients whose
GORD symptoms arise principally when
they are in the supine position.
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An OTC H2 antagonist dose starts reducing gastric acid concentration
within 1 to 2 hours after dosing and
lasts for at least nine hours. The combination of an H2 antagonist and an
antacid should provide both antacid
speed of symptom relief and H2 antagonist sustained duration of action.
However, patients should not take an
antacid at exactly the same time as the
H2 antagonist. It is best to wait an hour
or so between taking an antacid and
the H2 antagonist.
• Proton pump inhibitors
Proton pump inhibitors (PPIs) lead to
a greater than 90% inhibition of acid
secretion which is long lasting (24
hours). Most PPIs do not work as fast
as antacids and doctors sometimes add
an antacid to a PPI for fast and longlasting symptom relief. PPIs are usually prescription-only medicines but
some PPIs have become available for
OTC use e.g. Lanzor® HB capsules.
OTC PPIs should not be used long
term (longer than two weeks) unless
prescribed by a doctor.
2. Irritable Bowel
Syndrome (IBS)
• H 2 antagonists e.g. ranitidine
(Zantac®)
Other OTC treatments include H2 antagonists but you should refer the patient to the pharmacist to prescribe
them. They could, for example, be
given to a patient who has tried antacids and has found them to be ineffective or only providing short-term
symptom relief.
Irritable bowel syndrome is a common
gastrointestinal syndrome characterised by chronic or recurrent symptoms
of abdominal pain or discomfort,
bloating and altered bowel habits. It is
estimated that fewer than 20% of patients with IBS seek medical advice for
their symptoms.
H2 antagonists work by inhibiting acid
production in the stomach. They
should not be prescribed OTC for children or pregnant women. Always re-
While the exact cause of IBS is unknown, sometimes diet, a gastrointestinal infection or a stressful situation
may trigger IBS. Symptoms of IBS
may include:
• Abdominal pain or cramping, varying in intensity
• Bloating, with or without flatulence
• Mucus in the stools
• Abnormal passing of stools, either
too frequently (e.g. more than 3 per
day i.e. diarrhoea-prone IBS), or too
infrequently (i.e. less than 3 per
week i.e. constipation-prone IBS).
Note: Passing a stool may relieve
symptoms.
• A change in stool appearance
• Straining or urgency to pass a stool
Remember, if a patient presents with
fever, black, bloody or mucus-containing stools, severe pain or weight loss, it
is important to refer them to a doctor.
Many people with IBS may be able to
control symptoms through changes in
diet and lifestyle. Some of these may
include:
• Regular exercise
• Leaving enough time to complete
a bowel movement
• Increasing fibre in the diet
• Not smoking
• Getting adequate rest and reducing
stress
Note:
• Diarrhoea-prone IBS sufferers are
treated differently to constipationprone IBS patients.
• There are several new prescriptiononly medicines that have become
available for the treatment of IBS.
Patients that suffer from IBS, therefore, are encouraged to speak to
their doctor.
• Dietary fibre
Constipation-prone IBS is initially treated
with a high-fibre diet and/or the use of
a fibre supplement e.g. Fybogel Orange®. If this approach is unsuccessful, an osmotic laxative containing
lactulose e.g. Duphalac® can be tried.
OTC Management
ABDOMINAL PAIN
• Antispasmodics
Antispasmodics may relieve cramping,
abdominal pain and bloating. Antispasmodics include medicines that directly affect intestinal smooth muscle
relaxation e.g. mebeverine (Colofac®)
and those that act via the cholinergic
nervous system e.g. dicyclomine e.g.
(Merbentyl®) and hyoscine butyl-bromide (e.g. Buscopan ®). The antispasmodics should be used on an asneeded basis in IBS.
• Antidiarrhoeal agents
Some patients may present with diarrhoea and loperamide (e.g. Imodium®)
may be given on an as-needed basis.
Note: Loperamide should not be used
in patients with constipation and
should be used with caution in patients
with alternating diarrhoea and constipation.
• Probiotics
Probiotics are ‘good’ bacteria that
colonise parts of the body and help
prevent pathogenic bacteria and yeasts
etc from over-populating the system.
The probiotics used in the gut are Lactobacillus and Bifidobacterium. Although
more research is needed, there seems
to be no doubt that the use of probiotics improves symptoms and is beneficial for patients suffering from IBS.
Remember:
It is important to emphasise to patients
that IBS should not have any long-term
adverse effects. IBS poses no increased
risk for future development of cancer
or other serious illnesses.
3. Food allergy
or intolerance
People with a food intolerance may report symptoms such as abdominal
pain, cramping, nausea or vomiting in
response to the ingestion of a particular food. The simple avoidance of the
offending food may be recommended,
although a dietician may need to be
[ Autumn 2007 ] SA Pharmacist’s Assistant
OTC Management
ABDOMINAL PAIN
Table 1: Sample products available for the OTC treatment of heartburn
Class
Antacid
Product
Composition
Comments
Eno®, active fruit Sodium bicarbonate, anhydrous citric Contains sodium – Use with caution in patients with high blood pressure
salt
acid, sodium carbonate
or kidney disease.
Rennie®
Calcium carbonate, magnesium car- Can safely be used in pregnancy
bonate
Maalox® Tablets Magnesium hydroxide, aluminium hy- Contra-indicated for patients taking tetracycline antibiotics. Use with caution in patients with kidney disease.
and Suspension droxide
Maalox Plus ® Magnesium hydroxide, aluminium hy- Simethicone has antifoaming or antibubbling activity. It acts in the stomTablets and Sus- droxide, simethicone
ach and intestines by altering the surface tension of gas and mucus bubbles
pension
enabling them to coalesce. Coalescence of gas bubbles accelerates the
passage of gas through the intestine either through belching, passing of
flatus, or increased absorption of gas into the bloodstream. Contra-indicated for patients taking tetracycline antibiotics.Use with caution in patients with kidney disease.
Mucaine ® Tab- Oxethazaine, aluminium hydroxide, Contra-indicated for patients taking tetracycline antibiotics. Use with caution in patients with kidney disease. Oxetacaine is an amide anaesthetic
lets and Suspen- magnesium hydroxide
that is stated to have a prolonged action. It is administered with antacids
sion
for the symptomatic relief of gastro-oesophageal reflux disease.
Alginate /
antacid
Gaviscon® Tab- Alginic acid, magnesium trisilicate, alu- Contains sodium – Use with caution in patients with high blood pressure
lets and Suspen- minium hydroxide, sodium bicarbon- or kidney disease. May be used during pregnancy.
ate
sion
H2 antagonists Zantac 75® tab- Ranitidine
lets
Proton pump
inhibitor
Lanzor® HB cap- Lansoprazole
sules
SA Pharmacist’s Assistant [ Autumn 2007 ]
consulted if the diet becomes too restricted by intolerance to certain food
groups.
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Do not take within 30 to 45 minutes of taking an antacid. Do not take for
longer than 2 weeks without consulting a doctor.
A food allergy differs from food intolerance because it involves an immune
response to the ingestion of a food.
Food allergy is most prevalent in children, especially infants. Any food can
cause a food allergy but cow’s milk, egg,
wheat, peanuts, fish and soya are common culprits.
Reactions may vary from a skin rash,
vomiting or asthma to a rare but serious anaphylactic reaction, which can
be life threatening. The best treatment
is to avoid the offending food, but
some doctors may attempt to reintroduce the food after 6-12 months. Most
children will grow out of a food allergy
by the age of 5 years.
Do not use OTC for longer than 14 days. Wait 1 hour or so between
taking an antacid and taking the PPI.
In summary
• The cause of abdominal pain can
vary from heartburn to food intolerance to irritable bowel syndrome.
• The possible cause of heartburn
can vary from eating spicy food or
lying down after eating a heavy meal
to more sinister causes, such as an
ulcer or cancer. Any patient who
presents with heartburn and certain
other symptoms should be referred
to the doctor.
• Irritable bowel syndrome is a common gastrointestinal syndrome
characterised by chronic or recurrent symptoms of abdominal pain
or discomfort, bloating and altered
bowel habits.
• The pharmacist’s assistant should
be able to recommend appropriate
treatment for patients presenting
with mild to moderate abdominal
pain in the pharmacy as well as be
able to refer patients appropriately
for further medical attention.
sapa
REFERENCES
1. Randall MD, Neil KE. Disease Management.
Pharmaceutical Press. 2004.
2. ‘Reflux oesophagitis discharge care’ Micromedex
1995-1998
3. Australian Prescriber Vol 24 No.3 2001
4. ‘Irritable Bowel Syndrome discharge care’
Micromedex 1995-1998
5. Modern Medicine of South Africa June 2002
6. Brady WM, Ogorek CP. Gastroesophageal reflux disease. The long and the short of
therapuetic options. PostGraduate Medicine
1996; 100(5).