Customer profile

• She has a burning pain behind her breastbone

• She also complains that she has an unpleasant taste in her mouth

• She has no other health problems and is not taking any other medicines.

Did your team member correctly identify that this customer has heartburn/acid reflux? If not, more information on heartburn and indigestion is available via a downloadable summary sheet.

What treatment was suggested?

• Alginates or antacids are recommended as first-line OTC choices for heartburn3

• Both treatments are fast acting, with alginates lasting for up to four hours, antacids for up to three hours4,5

• Gaviscon Advances is an example of an alginate treatment

• Alginates’ mode of action also help stop the reflux of bile and pepsin, as well as acid5

• Not all alginates are the same. Due to differences in their chemical linking some alginates create a stronger, more resilient anti-reflux barrier than others6

• Second-line options include H2- receptor antagonists and proton pump inhibitors.3 These are longer lasting but onset of action is also longer.7,8

Products for gastrointestinal conditions are among the top five biggest selling OTC categories in pharmacy.1 What your team may not realise is that how symptoms can overlap. For example, customers can experience heartburn and indigestion interchangeably or at the same time,2 so asking the right questions in order to recommend an appropriate treatment is important.

As a team, role play how you would manage the following customers. Have your team/team member play their usual role, while you take the part of the customer.

Customer 1: A 35-year old woman:

“I’ve got a burning pain in my chest that stopped me sleeping last night.”

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Training your team: Heartburn and indigestion exercise

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Customer profile

• He has had indigestion in the past but only when he has eaten or drunk too much

• He has his usual symptoms: discomfort under his ribs, a burning pain in his chest and coming up into his mouth

• He is taking paracetamol for a bad back at the moment.

Did your team member correctly identify that this customer has both heartburn/acid reflux and indigestion symptoms? Around one in five customers with upper GI problems experience heartburn and indigestion at the same time.2 If not, more information on heartburn and indigestion is available via a downloadable summary sheet.

What treatment was suggested?

• A double-action treatment could be advised to manage both the indigestion and heartburn symptoms

• A treatment that contains an alginate plus antacid can be a good choice (e.g. Gaviscon Double Action)

• An H2-receptor antagonist (e.g. Gavilast) can also tackle all symptoms, but onset of action is longer than with antacids or alginates and it is usually recommended as a second-line option for persistent symptoms.3,8 In addition, H2-receptor antagonists tackle only acid-related symptoms, with no effect on bile or pepsin.10

Customer 2: A middle-aged man:

“I’ve got indigestion, what’s the fastest treatment to get rid of it?”

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Customer profile

• She has gastro-oesophageal reflux disease, recently diagnosed by her GP

• She takes a proton-pump inhibitor every day

• She has found this has helped her symptoms, but she still experiences some heartburn

• She is not taking any medicines currently and has no other medical conditions.

Did your team member correctly refer this customer to you? There is a need to make the customer aware that PPIs, such as omeprazole, start to work after a day or so, with benefits increasing after three to four days.7 In addition, around 45% of people taking PPIs will still experience occasional breakthrough symptoms.11 For both of these customers, an alginate or antacid can be recommended to provide relief.7

More information is available in the managing heartburn and indigestion module.

Was format considered?

• Heartburn and indigestion products are available as either tablets or liquids

• Customers may find tablets are more convenient for on-the-go relief.

What lifestyle advice was offered?

• Team members should recommend customers eat healthily, lose weight and stopping smoking (if necessary), eating small meals frequently and managing stress4,12

• Avoiding caffeine drinks, alcohol, spicy or fatty foods or eating within three to four hours of going to bed can also help4,12

• Raising the head of the bed a few inches can help with nocturnal heartburn symptoms.12

Customer 3: A 43-year old woman:

For all customers

“I need something effective to manage my heartburn.”

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References

1. Proprietary Association of Great Britain. Annual Review 2016-17. Accessed March 2018. https://www.pagb.co.uk/latest-news/pagb-annual-review-2016-17/ 2. RB. GI Segmentation Research. Data on file. 3. NICE Clinical Knowledge Summaries. Dyspepsia - unidentified cause. May 2017. Accessed March 2018. https://cks.nice.org.uk/dyspepsia-unidentified-cause 4. NHS Choices. Indigestion. Accessed March 2018. http://www.nhs.uk/conditions/indigestion/pages/introduction.aspx 5. Gaviscon Advance Peppermint Flavour. Summary of Product Characteristics. October 2014. Accessed March 2018. https://www.medicines.org.uk/emc/medicine/10860 6. Hampson FC, et al. Int J Pharmaceut, 2005;294:137-47. 7. Royal Pharmaceutical Society. Proton pump inhibitors as pharmacy medicines. A quick reference guide. May 2017. Accessed March 2018. https://www.rpharms.com/resources/quick-reference-guides/proton-pump-inhibitors 8. Gardner JD, et al. Aliment Pharmacol Ther 2002; 16: 1317–26. http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2036.2002.01291.x/epdf 9. Gaviscon Double Action Mint. SPC. Accessed March 2018. www.medicines.org.uk/emc/medicine/23351 10. Patient UK. H2 blockers. Accessed March 2018. https://patient.info/health/h2-blockers. 11. El-Serag H, et al. Aliment Pharmacol Ther, 2010;32:720-37. 12. NICE. Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. Clinical guideline. September 2014. http://nice.org.uk/guidance/cg184

Essential Information

Gaviscon Advance Peppermint Flavour Suspension: Each 10ml dose contains sodium alginate 1000.0mg and potassium hydrogen carbonate 200.0mg. 1ml contains sodium alginate 100.0mg and potassium hydrogen carbonate 20.0mg. Indications: Treatment of symptoms of gastro-oesophageal reflux such as acid regurgitation, heartburn, indigestion occurring due to the reflux of stomach contents, for instance, after gastric surgery, as a result of hiatus hernia, during pregnancy or accompanying reflux oesophagitis. Dosage and Administration: Adults and children 12 years and over: 5-10 ml after meals and at bedtime. Children under 12 years: Should be given only on medical advice. Duration of treatment: If symptoms do not improve after seven days, the clinical situation should be reviewed. Elderly: No dose modification is required for this age group. Hepatic Impairment: No modifications necessary. Contraindications: Hypersensitivity to the active substances or to any of the excipients, including methyl parahydroxybenzoate (E218) and propyl parahydroxybenzoate (E216). Precautions and Warnings: If symptoms do not improve after seven days, the clinical situation should be reviewed. Each 10 ml dose has a sodium content of 106 mg (4.6 mmol) and a potassium content of 78 mg (2.0 mmol). This should be taken into account when a highly restricted salt diet is recommended, e.g. in some cases of congestive cardiac failure and renal impairment or when taking drugs which can increase plasma potassium levels. Each 10 ml contains 200 mg (2.0 mmol) of calcium carbonate. Care needs to be taken in treating patients with hypercalcaemia, nephrocalcinosis and recurrent calcium containing renal calculi. Contains methyl parahydroxybenzoate (E218) and propyl parahydroxybenzoate (E216): May cause allergic reactions (possibly delayed). Pregnancy and Lactation: Pregnancy: Clinical studies in more than 500 pregnant women as well as a large amount of data from post-marketing experience indicate no malformative nor feto/neonatal toxicity of the active substances. Gaviscon can be used during pregnancy if clinically needed.Breastfeeding: No known effect on breastfed infants. Gaviscon can be used during breastfeeding. Side effects: Very rarely (<1/10,000) patients develop allergic manifestations such as urticaria or bronchospasm, anaphylactic or anaphylactoid reactions. Legal Classification: P. Licence Holder: Reckitt Benckiser Healthcare (UK) Limited, Dansom Lane, Hull, HU8 7DS, UK. Licence Number: PL 00063/0103. MRRP: £4.99 (150 ml); £8.99 (300 ml). Last Revised: April 2016.

Gaviscon Advance Aniseed Suspension. Each 10 ml dose contains sodium alginate 1000.00mg and potassium hydrogen carbonate 200.00mg. Indications: Treatment of symptoms resulting from the reflux of acid, bile and pepsin into the oesophagus such as acid regurgitation, heartburn, indigestion (occurring due to the reflux of stomach contents), for instance, after gastric surgery, as a result of hiatus hernia, during pregnancy, accompanying reflux oesophagitis, including symptoms of laryngopharyngeal reflux such as hoarseness and other voice disorders, sore throats and cough. Can also be used to treat the symptoms of gastro-oesophageal reflux during concomitant treatment with or following withdrawal of acid suppressing therapy. Dosage and administration: Adults and children 12 years and over: 5-10 ml after meals and at bedtime. Children under 12 years: Should be given only on medical advice. Elderly: No dose modification is required for this age group. Contraindications: This medicinal product is contraindicated in patient with known or suspected hypersensitivity to any of the ingredients, or any of the excipients, including methyl parahydroxybenzoate (E218) and propyl parahydroxybenzoate (E216). Precautions and Warnings: Each 10 ml dose has a sodium content of 106 mg (4.6mmol) and a potassium content of 78 mg (2.0 mmol). This should be taken into account when a highly restricted salt diet is recommended, e.g. in some cases of congestive cardiac failure and renal impairment or when taking drugs which can increase plasma potassium levels. Each 10 ml contains 200 mg (2.0 mmol) of calcium carbonate. Care needs to be taken in treating patients with hypercalcaemia, nephrocalcinosis and recurrent calcium containing renal calculi.Treatment of children younger than 12 years of age is not generally recommended, except on medical advice. If symptoms do not improve after seven days, the clinical situation should be reviewed. Contains Methyl parahydroxybenzoate and Propyl parahydroxybenzoate, which may cause allergic reactions (possibly delayed). Pregnancy and Lactation: Pregnancy: Clinical studies in more than 500 pregnant women as well as a large amount of data from post-marketing experience indicate no malformative nor foeto/neonatal toxicity of the active substances. Gaviscon can be used during pregnancy, if clinically needed. Breast feeding: No known effect on breast fed infants. Gaviscon can be used during breast feeding. Side effects: Very rarely (<1/10,000) patients may develop allergic manifestations such as urticaria or bronchospasm, anaphylactic or anaphylactoid reactions. Legal Classification: P. Licence Holder: Reckitt Benckiser Healthcare (UK) Limited, Dansom Lane, Hull, HU8 7DS, UK. Licence Number: PL 00063/0108. MRRP: £4.99 (150ml); £8.99 (300ml). Last Revised: April 2017.

Gaviscon Advance Aniseed Flavour Oral Suspension: Each 10ml dose contains sodium alginate 1000.0mg and potassium hydrogen carbonate 200.0mg. Indications Treatment of symptoms resulting from the reflux of acid, bile and pepsin into the oesophagus such as acid regurgitation, heartburn, indigestion (occurring due to the reflux of stomach contents), for instance, after gastric surgery, as a result of hiatus hernia, during pregnancy, accompanying reflux oesophagitis, including symptoms of laryngopharyngeal reflux such as hoarseness and other voice disorders, sore throats and cough. Can also be used to treat the symptoms of gastro-oesophageal reflux during concomitant treatment with or following withdrawal of acid suppressing therapy. Legal Classification: GSL. MRRP: £4.99 (150ml); £8.99 (300ml). Licence Holder: Reckitt Benckiser Healthcare (UK) Limited, HU8 7DS, UK. Information about this product, including adverse reactions, precautions, contra-indications, and method of use can be found at: https://www.medicines.org.uk/emc/medicine/33726 Last revised: April 2017.

Gaviscon Double Action Mint: 10 ml dose contains sodium alginate 500mg, sodium bicarbonate 213mg and calcium carbonate 325mg. Indications: Treatment of symptoms resulting from the reflux of acid, bile and pepsin into the oesophagus such as acid regurgitation, heartburn and indigestion, for example following meals or during pregnancy, and for symptoms of excess stomach acid (hyperacidity). Can also be used to treat the symptoms of gastro-oesophageal reflux during concomitant treatment with or following withdrawal of acid suppressing therapy. Legal classification: GSL. MRRP: £4.99 (150ml); £8.49 (300ml); £13.99 (600ml). Licence Holder: Reckitt Benckiser Healthcare (UK) Limited, HU8 7DS, UK. Information about this product, including adverse reactions, precautions, contra-indications, and method of use can be found at: www.medicines.org.uk/emc/medicine/23351

Gavilast 75mg Tablets: Ranitidine 75 mg. Indications: For the short-term symptomatic relief of acid indigestion and heartburn. Legal classification: GSL. MRRP: £4.32 (12 tablets). Licence Holder: Ranbaxy (UK) Ltd, London, W4 5YE, U.K. Information about this product, including adverse reactions, precautions, contra-indications, and method of use can be found at: https://www.medicines.org.uk/emc/medicine/26996 Prepared 13th September, 2012

All adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard.Adverse events should also be reported to Reckitt Benckiser Healthcare UK Ltd on 0333 200 5345. U

K/C

C/0417/0005bc D

ate of preparation: March 2018

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