With GERD affecting approximately one in four Canadians,1 pharmacists like Susie Jin from Cobourg, Ont. are taking an active role in ensuring all of their patients are reaching optimal gastrointestinal outcomes.
By Mike Boivin, BSc.Phm.
Photography by Brandon Gray
Susie feels that through the pharmacist’s expanded role, she can take a more active role in patient management. “At Pharmacy 101, our primary focus is to develop long-term relationships with our patients. This allows us the opportunity to work with our patients to ensure they are achieving the best results with their current therapy.”
There is a wide variation in the clinical presentation of GERD patients seen in Susie’s practice. “It is common for pharmacists to see patients with occasional heartburn symptoms when they something spicy or overindulge. I also see patients who are still experiencing significant GERD symptoms even though they are taking pharmacotherapy.” Susie also tries to identify patients who may be at risk of GERD: obese people, older patients, smokers, those with a positive family history of gastrointestinal disease, and patients with a high cholesterol diet.2
“Through discussions with GERD patients, you quickly realize the impact of the condition on a patient’s health-related quality of life,” Susie adds. “I feel that pharmacists are ideally positioned to screen and intervene in patients who are failing to respond to their current GERD treatment.”
When screening patients she assesses the frequency and severity of symptoms, as well as the impact of the symptoms on the patient’s quality of life. The screening provides a clearer picture of those options that best address a patient’s clinical presentation. “Through proper screening and patient engagement, I can recommend the right medication, for the right patient, at the right time.”
Patients with mild GERD3 (mild symptoms affecting a patient < 3 times per week) can be effectively managed with OTC products such an H2-blocker and/or an antacid.3 The problem occurs when patients with moderate to severe GERD (such as those with persistent symptoms, three or more times per week)3 are managing their GERD with these OTC agents.
“I see this in practice all the time. Antacids and H2-blockers are not effective in patients with more severe and persistent symptoms3, but they continue to take them hoping their condition will improve.” In her practice, Susie identifies these patients and refers them to their physicians for further assessment and a treatment change. “Many of these patients don’t even realize there are better options available. By increasing awareness of better options, pharmacists can reduce the impact GERD on these patients.”
Susie frequently assesses and intervenes in patients taking proton-pump inhibitor (PPI) therapy with a suboptimal response. “It is a common misconception that patients on PPI therapy are always reaching their treatment targets. I have been asking about the incidence of breakthrough symptoms and I am surprised to see how commonly they actually occur.”
It is estimated that up to 40 per cent of patients treated with a PPI will still experience GERD symptoms.4 Forty-five per cent of patients on PPI therapy in observational trials were found to have persistent, troublesome typical symptoms of GERD (heartburn and regurgitation).4
“When I discover patients on PPI therapy who are still experiencing symptoms, I first check adherence to medication and how they are taking their therapy.” This is an important step, as only 60 per cent of patients were found to be adhering to PPI therapy, and more than half of patients were not taking their PPI therapy.4 Susie stresses the importance of adherence and the need to take most PPI therapies before a meal to maximize their efficacy.4
Pharmacists can use the validated PASS test to screen GERD patients on pharmacotherapy to determine the response to treatment and to discover if their GERD patients are optimally managed.5 “In patients who are fully adherent but are still experiencing GERD symptoms, I commonly recommend a different PPI therapy,”4 Susie notes.
1. Are you still experiencing stomach symptoms? Yes No
2. In addition to your main medication, are you taking any of the following medications to control your symptoms:
• Motility drugs
• Others Yes No
3. Is your sleep affected by your stomach symptoms? Yes No
4. Are your eating and drinking habits affected by your stomach symptoms? Yes No
5. At any time do your stomach symptoms interfere with your daily activities? Yes No
By actively engaging her patients with GERD and assessing their response to therapy, Susie Jin is a model of what pharmacists can do to help reduce the impact of this very common condition on patients’ quality of life.
1. El-Serag HB, Sweet S, Winchester CC, Dent J. Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut. 2013. doi:10.1136/gutjnl-2012-304269.
2. Fedorak RN, van Zanten SV, Bridges R. Canadian Digestive Health Foundation Public Impact Series: Gastroesophageal reflux disease in Canada: Incidence, prevalence, and direct and indirect economic impact. Can J Gastroenterol. 2010;24(7):431. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2918483/. Accessed August 9, 2013.
3. Armstrong D, Marshall JK, Chiba N, et al. Canadian Consensus Conference on the management of gastroesophageal reflux disease in adults – update 2004. Can J Gastroenterol. 2005;19(1):15-35.
4. Katz PO, Gerson LB, Vela MF. Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol. 2013;108(3):308-328. doi:10.1038/ajg.2012.444.
5. Armstrong D, Veldhuyzen SJ, Chung SA, et al. Validation of a short questionnaire in English and French for use in patients with persistent upper gastrointestinal symptoms despite proton pump inhibitor therapy: the PASS (Proton pump inhibitor Acid Suppression Symptom) test. Can J Gastroenterol J Can Gastroenterol. 2005;19(6):350-358.