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Pharmacy Training

OTC Expert 2019 Digestive Health Pharmacy Training

By December 13, 2019 January 7th, 2020 No Comments

digestive health pharmacy training mediapharmDigestive 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.

The Department of Health and Social Care has now restricted some of the medicines that can be prescribed for indigestion and heartburn, infrequent constipation, adult diarrhoea and travel sickness. In a bid to cut NHS costs, it views these as short-term self-limiting conditions which people can treat themselves with self-care and OTC medicines. Many gluten-free foods (e.g. pasta) are also on that list with only bread and flour mixes now possible to prescribe.

GPs will, therefore, be referring many patients with digestive problems to the pharmacy for advice and recommendations.

Pharmacy Value

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 standalone service.

As part of the pharmacy contract, your pharmacist is required to conduct an audit to review all patients aged 65 years and overprescribed a non-steroidal anti-inflammatory (NSAID) drug to make sure they are also being prescribed gastroprotective medicines.  Talk to your pharmacist about this so you can support them and answer any patient questions. 

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. 

Ranitidine Recal

Ranitidine is an H2 antagonist available on prescription and OTC. Ranitidine reduces the amount of acid produced by the stomach and can provide relief from indigestion and heartburn. In October 2019, it was recalled as a precaution because of concerns over contamination.

If customers have been prescribed it, refer them to their GP. Anyone that has OTC ranitidine at home (e.g. Zantac or Gavilast) should be advised to stop taking it and an alternative recommended.

The Digestive System

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 (covered in the Holiday Health module) 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.

Gut microbiome

Microbiome refers to all the ‘friendly’ bacteria that live within the human digestive tract. These bacteria are thought to bring many health benefits, such as helping break down our food, supporting our immune system, and helping to protect us against any disease-causing microbes that may get into the gut.

When this balance of good bacteria is upset, e.g. poor diet or antibiotics, gut problems may occur. These are thought to include diarrhoea and irritable bowel syndrome. Research is still being carried out in this area. 

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.

Symptoms

Indigestion refers to symptoms that affect the stomach and the oesophagus (the gullet). Click on the hot spots to see the types of symptoms associated with indigestion.

Causes

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. Always check this with the pharmacist before recommending treatments.

Causes

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 (e.g. found in Maalox Plus), calcium carbonate (e.g. found in Rennie) and sodium bicarbonate (e.g. found in Bisodol). 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 and dimeticone

Simeticone can be found in combination products with an antacid or on its own (e.g. Wind-Eze), and helps to relieve wind. Dimeticone is also available (e.g. WindSetlers).

Bismuth

Bismuth (e.g. Pepto-Bismol) coats the lining of the stomach and prevents irritation.

Heartburn

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 and examples include Gaviscon Advance (sodium alginate and potassium bicarbonate) and Gaviscon Double Action (sodium alginate, sodium bicarbonate, calcium carbonate).

Proton pump inhibitors

Proton pump inhibitors (PPIs) e.g. omeprazole and esomeprazole (Nexium Control) 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’.

Symptoms

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 bulk-forming 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. Examples include ispaghula (Fybogel Hi-Fibre), methylcellulose (Celevac) and sterculia (Normacol).

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 (e.g. Duphalac) and magnesium sulphate (Andrews Salts, which also has an antacid in it). 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 and is found in Dulcoease.

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. Examples include senna (e.g. Senokot) and bisacodyl (Dulcolax tablets).

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
  • If 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.

Symptoms

The symptoms can vary between people and between attacks. Click on the hot spots below to find out more about symptoms.

Other food-related conditions

Food allergies

A food allergy is when the body’s immune system reacts unusually to specific foods. Allergic reactions are usually mild but they can be very serious leading to anaphylaxis. 

Food allergies seem to be on the rise and there has been a lot of high profile cases in the news recently. Food labelling is an important issue as is making sure people get treatment fast. 

Food allergy symptoms vary but commonly include:

  • Itchy mouth, throat or ears
  • Raised itchy red rash 
  • Swelling of the face, around the eyes, lips, tongue and roof of the mouth 
  • Vomiting

In anaphylaxis the symptoms will include:

  • Breathing difficulties
  • Trouble swallowing or speaking
  • Feeling dizzy or faint

In cases of anaphylaxis, calling an ambulance is a priority. Some people who have known food allergies may carry their own adrenaline injection (e.g. Epipen). 

Food intolerance

A food intolerance is not an allergy and is not related to the immune system. It is caused by difficulties digesting certain substances, such as wheat or lactose in milk. 

Symptoms include diarrhoea, bloating and stomach cramps. 

Food allergy vs food intolerance

Food allergy and intolerance differ in the following ways:

  • Symptoms of a food intolerance usually occur several hours after eating the food
  • Larger amounts of food are needed to trigger an intolerance than an allergy
  • Unlike an allergy, food intolerance is never life-threatening

Coeliac disease

Coeliac disease is not a food allergy or intolerance, it is an autoimmune disease where the body’s immune system attacks itself when gluten (a protein in wheat, barley and rye) is eaten. This leads to damage to the lining of the gut wall and affects its normal function to absorb food. 

Some symptoms of coeliac disease are often mistaken for IBS and some blamed on stress or ageing. People need to be referred to the doctor to confirm the cause before eliminating any foods from the diet.

Coeliac patients may be prescribed gluten-free bread and flour but there are other gluten-free foods that are available to buy. A dietitian would also work with patients to guide them on following a gluten-free diet.

IBS Treatments

The pharmacy can only recommend treatment for people who have already been diagnosed with IBS by their doctor.

Treatment should target the symptoms the customer is suffering from:

  • Diarrhoea – loperamide (for example Imodium and Diocalm Ultra) 
  • Constipation – if dietary changes do not work, bulk-forming laxatives (e.g. Fybogel) can be recommended
  • Abdominal pain, spasms and wind – antispasmodics relax stomach muscle contractions that can cause stomach pain and cramps. Examples include mebeverine (Colofac IBS), hyoscine (Buscopan IBS Relief) and peppermint oil (e.g. Colpermin). Simeticone (e.g. Remegel Wind Relief or Rennie Deflatine) can help to relieve trapped wind. Check age restrictions and if people are on other medication. For example, hyoscine cannot be used in people with glaucoma (a condition related to raised pressure in the eyes).
  • Probiotics – Probiotics are live bacteria and yeasts promoted as having various health benefits by restoring the balance of gut bacteria. They are usually added to yoghurts or taken as food supplements and are often described as ‘good’ or ‘friendly’ bacteria. Prebiotics are also available – these are compounds that the live micro-organisms feed on to promote their growth.

NHS advice is that people with IBS who choose to try probiotics should take them for at least 4 weeks, at a dose recommended by the manufacturer, to see if they help.

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 a sufferer has not been diagnosed with IBS
  • If there is also weight loss
  • If there is blood in the stools/stools appear dark
  • If a sufferer also has anaemia-like symptoms (tiredness, breathlessness, palpitations, dizziness and headache)

Note: As the symptoms of IBS can be vague and similar to other conditions, all patients with symptoms suggestive of IBS should be referred to the pharmacist.

Engaging customers

Making every contact count (MECC) is an approach to healthcare that encourages all those who have contact with the public to talk about their health and wellbeing. Pharmacy assistants working on the counter can make a huge difference here especially when it involves customers changing their behaviour and adopting good habits, for example around managing irritable bowel syndrome (IBS), indigestion and heartburn which can be managed by lifestyle changes. Being a Healthy Living Pharmacy (HLP) also means getting involved in health promotion and awareness campaigns such as helping customers lookout for bowel cancer symptoms. 

Top tips for starting conversations

Self-care advice is all about using opening lines that make an impact – these are called ‘brief interventions’. Use a hook such as holidays or festive celebrations as a starting point. Hers are some more suggestions: 

  • If people are overweight, losing weight can help with indigestion symptoms. Offer advice on weight management, or signpost to a pharmacy weight management service where appropriate
  • People with constipation should try to take more exercise if possible. Adults should take at least 150 minutes of moderate-intensity aerobic activity (such as cycling or fast walking) every week
  • Smoking can aggravate indigestion, so ask anyone with indigestion whether they smoke and advise them to quit if they do. Signpost to an NHS Stop Smoking service if appropriate.
  • If customers are suffering from generalised gastrointestinal symptoms they may have a  food intolerance and a food diary used over 2 weeks will help them pinpoint the culprit

Don’t forget to recommend add-on products when it is appropriate, for example: 

  • Probiotics may help improve digestive health. Probiotic supplements could be recommended to people with IBS
  • Offer smoking cessation products for people who smoke and want to quit.
  • Offer gluten-free foods for people with a gluten intolerance 

Added value advice

  • Promote your self-care service to your customers – digestive health problems are so common that you should always highlight the support you can offer in the pharmacy
  • Consider the time of year– Christmas is traditionally a time of overindulgence and you should ensure that you keep appropriate stock to deal with requests for products for indigestion. Summer holidays is another time to consider raising awareness of this category
  • Use leaflets to raise awareness of digestive health products and brands
  • Get involved with awareness campaigns for conditions such as IBS and bowel cancer. People can be reluctant to discuss digestive problems because of embarrassment, so raising awareness through posters and leaflets can encourage them to seek help

Why Buy This Course?

Pharmacy owners are responsible for meeting GPhC Principle 2 requirements for support staff training. This course makes it easy for owners to demonstrate their staff are up to date with the latest knowledge and skills. This course includes:

  • Personalised certificate as evidence of completion
  • Video tutorials to engage learners
  • Case scenarios to reinforce key learning points
  • Multiple choice quiz to embed learning
  • Structured learning plan

Learning outcomes

By the end of this course you will be able to:

  • Recognise the symptoms of indigestion, heartburn, constipation and IBS
  • Recommend treatments for these conditions where appropriate
  • Recognise food allergies, food intolerance and coeliac disease and advise appropriately
  • Know when to refer customers to the pharmacist

Duration

This course will take approximately 20 minutes to complete. The videos are additional and optional but have been included to accommodate different learning styles and to help enhance the learning.

Why is this digestive health pharmacy training course important?

Digestive health problems are common complaints in the pharmacy and symptoms can affect any point of the digestive tract. However, customers often find the conditions, and terms used to describe them, confusing and they will be asking you for help. Understanding customers’ symptoms mean you can help them find the treatment they need to get them back on track.


This post was created on behalf of MediaPharm by Nicola Hasted from Pharmacy Mentor