Community Pharmacy

Training your Pharmacy in Gut Health

Digestive health is in the top 5 over-the-counter (OTC) categories and spans ailments across both the upper and lower gastrointestinal tract. So digestive health pharmacy training is a priority.

Customers value a dedicated consultation away from the shop floor where they can discuss their concerns and needs more openly. Advice for digestive health can form part of the travel clinic (e.g. around holiday diarrhoea, travel sickness, waterborne infections) or as a stand-alone service.

There has been a lot of press about severe and sometimes fatal cases of food allergies. Understanding these means you can help advise customers on reducing the risks, what symptoms to look for and why it is important to seek help immediately. For those who have a known food allergy then reminding them to always carry their emergency adrenaline auto-injector is important.

Digestive health covers a multitude of gastrointestinal (GI) problem.

These can be upper GI problems affecting the stomach and oesophagus (food pipe), such as indigestion, heartburn, nausea and vomiting. Or they can be lower GI problems affecting the bowels (intestine and colon) and rectum (back passage), such as diarrhoea, constipation and haemorrhoids.

Add to that the ‘holiday health’ conditions of travel sickness and traveller’s diarrhoea and you can see why GI problems are commonplace in the pharmacy.

While many GI problems can be managed with OTC treatments and lifestyle changes, they can persist. They may also be a sign of more serious conditions such as bowel cancer. So, you have an important role to play in spotting when this might be the case and referring these customers for medical help.

Indigestion
Customers with indigestion may complain of many different symptoms as it is often a bit of a catch-all for anything that is not going quite right with the upper part of the GI tract. It is therefore important to get a full picture of the symptoms so you know what you are dealing with.

Indigestion (also called dyspepsia) occurs when stomach acids start to irritate the lining of the digestive tract. It usually occurs soon after eating or drinking.

Indigestion refers to symptoms that affect the stomach and the oesophagus (the gullet).

There are a number of things that can worsen symptoms or make a customer more likely to suffer, including:

• High alcohol intake
• Eating heavy or spicy meals
• Being overweight
• Smoking
• Taking certain medicines such as non-steroidal anti inflammatory drugs (NSAID e.g. ibuprofen)
• Certain medical conditions e.g stomach ulcers, hiatus hernia, stomach cancer

Patients who suffer from indigestion regularly should be given lifestyle advice on the above and be referred to the pharmacist.

NOTE: Patients who are on prescribed NSAIDs are also being targeted by pharmacists for a medication review to make sure there are no long term problems associated with their use. Check with your pharmacist if they want you to get involved in identifying and referring on these customers.

Heartburn
Heartburn (also called acid reflux) is a specific type of indigestion that develops when the acid contents of the stomach flow back up the oesophagus.

People who say they have indigestion may also have heartburn so you should check the symptoms so the correct product can be recommended.

Symptoms
• Burning sensation behind the chest bone and back of the throat
• Bitter taste in the mouth
• Regurgitation of stomach acid

The pain can be so bad that sufferers think they are having a heart attack.

Heartburn develops when the acid contents of the stomach flow back up the oesophagus. There is a muscle, called a sphincter, which sits at the top of the stomach and acts as a lid to keep stomach acids in place. Sometimes this sphincter gets a bit weak or gets put under too much pressure, allowing acid to flow back up into the oesophagus.

Triggers for heartburn include:
• Alcohol
• Smoking
• Caffeine drinks
• Citrus fruits
• Fatty and/or spicy foods
• Large portions of food
• Being overweight
• Being pregnant
• Wearing tight clothes

INDIGESTION TREATMENTS

Antacids
Antacids work by neutralising excess acid produced by the stomach. They act quickly but the effects don’t last long so this means repeat doses may be required. Many products contain a combination of the following: aluminium and magnesium salts and sodium bicarbonate.

Constipation (caused by aluminium salts) and diarrhoea (caused by magnesium salts) are possible side effects, so check the packaging ingredients and alert customers to stop taking them if they experience any of these.

Simeticone can be found in combination products with an antacid or on its own.

Bismuth coats the lining of the stomach and prevents irritation.

If heartburn is particularly troublesome the following may be recommended:

Alginates
Alginates form a raft at the top of the stomach stopping acids from flowing upwards into the oesophagus and causing heartburn. They are fast-acting and usually taken after meals and before bedtime. They are combined with an antacid.

Proton pump inhibitors
Proton pump inhibitors (PPIs) block stomach acid production. They usually take 2 to 4 days for the full effect to be felt. They are taken as a short course of 2-4 weeks (refer to individual products for details) and should be discontinued as soon as symptoms are relieved. Patients should be referred to the doctor if symptom relief is not achieved within two weeks.
Note: PPIs must not be taken by people on warfarin or by those already taking H2 antagonists. PPIs can also interact with other medicines so always check with the customer if they are taking anything else.

When to refer
There may be other occasions when it is necessary to refer a customer to the pharmacist but here are a few examples when it will be necessary:

• Anyone asking for large amounts of indigestion remedies
• Over 45 years of age and experiencing indigestion or heartburn for the first time
• Over 55 years of age and having recurring indigestion
• Unexplained weight loss
• Difficulty in swallowing
• Pain in the centre of the chest
• If the pain is also felt in the neck, shoulder and down the left arm (may indicate a heart problem)
• Pregnant woman with heartburn

• If there is no relief from heartburn after taking a proton pump inhibitor for two weeks
• Persistent vomiting
• Iron deficiency (anaemic)
• Blood in vomit or stools
• If a person is taking other medication e.g. warfarin cannot be taken with PPIs

Constipation
If you ask someone what their normal bowel habit is, you’ll find the answer varies widely. The important thing to recognise is that there is no definite rule for what is ‘normal’.

The symptoms can occur over a short period of time, or it can be a chronic condition and can include:

• Having to go to the toilet less than usual
• Going to the toilet as often but having small, hard stools (or straining to pass a stool)
• Stomach ache or cramps
• Feeling bloated or nauseous
• Loss of appetite

Causes
It can be difficult to identify the exact cause of constipation, but some common causes include:

• Lack of fibre in the diet
• Not drinking enough fluids
• Lack of exercise
• Medicines that cause constipation as a side effect e.g. codeine-containing pain relievers, aluminium containing antacids
• Pregnancy (due to increased pressure in the abdomen and hormone changes)
• Ignoring the urge to pass a stool
• Change in routine/lifestyle (e.g. going on holiday)
• Anxiety
• Old age
• Cancer

Constipation Treatments
If lifestyle and dietary measures alone haven’t helped to relieve constipation, a laxative can also be used. These are available as tablets, capsules, liquids, granules, and suppositories (inserted into the rectum [back passage]). Many of these should not be used in children.
The main types of laxatives available are listed below. A bulkforming laxative might be the first choice but they can take time to work and if the person is looking for quicker relief then an alternative laxative might be recommended. This should form part of WWHAM.

Bulk-forming laxatives
These contain natural fibre and work by bulking out the stools to help the intestine (small bowel) move the stools faster. They also retain more water in the stool, making them softer and easier to pass. They can take a few days to work and users should be advised to drink plenty of water.

Osmotic laxatives
These retain water in the bowel, helping to soften stools. They can take up to three days to take effect and examples include lactulose and magnesium sulphate. Lactulose is unsuitable for people with lactose intolerance.

Stool softeners
These work by softening stools and making them easier to pass. Docusate sodium is a stool softener.

Stimulant laxatives

These promote the movement of stools through the bowel so less water is absorbed and stools become softer and easier to pass. They act quickly (6-12 hours if taken as a tablet, even less if a suppository is used). The dose should be taken at night time, and they should be used short-term only for occasional constipation, otherwise, the bowel can become ‘lazy’, not working correctly without a stimulant. They can cause cramping. When to refer
There may be other occasions when it is necessary to refer a customer to the pharmacist but here are a few examples when it will be necessary:

• If there is any major change in bowel habits, especially in the middle-aged or elderly customer (could indicate a more serious problem such as bowel cancer)
• If there is blood or mucus in the stools
• Unexplained weight loss
• Loss of appetite
• If constipation persists for more than a week, despite lifestyle changes and short-term laxative use
• Severe pain when trying to pass stools
• When large amounts/regular purchases of laxatives are requested
• If the customer is a child
• If the customer is on other medication

IBS
Abdominal pain and cramping is a relatively common complaint. One condition which could be the cause is irritable bowel syndrome (IBS), which needs to be diagnosed by a doctor. It is a long-term condition that affects up to 20% of people at some time in their life and is more common in women.

There is no known cause for IBS, though in some people it started after a period of stress or a GI infection. Once people have IBS, recurrent bouts may be brought on by different triggers e.g. stress or certain foods.

 

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