1. Pharmaceutical guidelines of patients with pathology of digestive organs. SYMPTOMATIC TREATMENT OF HEARTBURN

2. HEARTBURN typically begins with a burning sensation that starts in the upper abdomen and moves up into the chest, often making its way to the back of the throat, and sometimes up into the jaw, arms and back. It usually feels worse when lying down or bending forward. One in 10 Americans experiences heartburn symptoms at least once a week.

3. Heartburn triggers Healthy people: fat-laden or acidic foods, medications (aspirin), obesity, drinking alcohol, smoking, eating chocolate, Pregnancy ( Gaviscon effectively and rapidly treats heartburn during pregnancy. Its use during pregnancy presents no known significant safety concerns for mother or child ) emotional turmoil, tension lying down

4. Heartburn causes Gastroesophageal Reflux (GERD) - stomach fluids containing acid and digestive enzymes back up past the valve-like sphincter that separates the stomach from the esophagus, causing pain. Gastrointestinal diseases: Chronic gastritis (B), stomach ulcer disease, chronic cholecyctitis diabetes, hiatal hernias, autoimmune disorders

5. Heartburn: An Inside Look Food travels through the esophagus to the stomach. A valve-like ring of muscle called the lower esophageal sphincter opens to let the food in. Then it's supposed to close again to prevent stomach acids from sliding up into the esophagus.

6. Heartburn: Faulty Valve In some people, the sphincter between the stomach and esophagus doesn't work as well as it should. This allows acid to seep into the esophagus (called acid reflux), where it can cause pain and irritation. Not everyone with acid reflux suffers from heartburn, and some people with "heartburn" symptoms don't actually have acid reflux but may have some other condition causing this pain.

7. Acid Reflux Symptoms The hallmark of acid reflux is heartburn -- a painful burning sensation in the middle of the chest. Heartburn typically strikes after meals and can last several hours. The discomfort may be worse after bending over or lying down. Other symptoms of severe acid reflux include a sour-tasting fluid in the back of the throat, difficulty swallowing, or feeling that food is stuck in the chest or throat. A chronic cough or asthma attacks can also be caused by acid reflux. A description of heartburn symptoms is usually all that’s needed to diagnose acid reflux.

8. Heartburn: Who’s at Risk? Anyone can develop heartburn, but certain lifestyle factors affect how well the sphincter works, as well as the amount of acid produced by the stomach. People who are overweight, eat large meals, wear tight-fitting clothes, or smoke tend to be more vulnerable.

9. Is it GERD? Heartburn usually doesn't pose a serious threat to health. However, complications can occur with severe, frequent, and persistent acid reflux. If someone have severe heartburn or heartburn two or more times a week, he may have a condition called GERD (gastroesophageal reflux disease). Without treatment, chronic GERD can cause inflammation, ulcers, and scarring. GERD can also lead to changes in the cells lining the esophagus. Known as Barrett's esophagus (shown here), compensation by growing more cells like the ones in the intestinal lining, these changes raise the risk of esophageal cancer.

10. Nighttime Heartburn Waking with a sore throat, cough, or a bitter taste in mouth - It could be nighttime acid reflux, and it could be dangerous. In addition to disturbing sleep, nighttime reflux increases the risk of esophageal damage. That's because lying down leaves stomach acid in the esophagus longer. And as we sleep we swallow less acid- neutralizing saliva than when awake.

11. Heartburn. Life-threatening symptoms Accompanied by chest pain that feels like a heart attack, persistent dry cough, vocal modification, hoarseness, a sensation of globus pharyngis (a lump at the back of the throat) and otalgia (ear pain) Abdominal pain or difficulty swallowing, weight loss, fever or signs of bleeding, including vomiting and black stools, which could indicate bleeding from the esophagus into the stomach Heartburn 3 days and more Heartburn connected with certain medicines

12. Managing Heartburn at Home Heartburn treatment may include medications, home remedies, or diet changes. Patient may be able to manage mild heartburn with a few changes to daily routine. Start by eating smaller meals. Finish dinner at least three to four hours before bedtime and avoid late- night snacks.

13. Foods Some foods are known to contribute to heartburn by bringing additional acid into the stomach or by relaxing the lower esophageal sphincter. Should avoid tomatoes, onions, garlic, chocolate, peppermint, fatty foods, and citrus fruits, including oranges and grapefruit.

14. Beverages Certain beverages can also bring on heartburn. These include coffee, tea, sodas, alcohol, tomato juice, and orange juice.

15. Heartburn During Pregnancy More than half of all pregnant women report symptoms of severe heartburn, especially during their second and third trimesters. Changing hormone levels and increased abdominal pressures during pregnancy increase the risk of acid reflux and heartburn. Mild symptoms should be treated with lifestyle changes, including eating several small meals a day instead of three large ones, avoiding fried and spicy foods, and not lying down after eating. If diet and lifestyle don't alleviate symptoms, pregnant women should consult their doctor before taking any medications.

16. Stop Smoking to Stop Heartburn Smoking weakens the valve at the end of the esophagus, which can lead to acid reflux and heartburn. And it increases the risk of various gastrointestinal cancers. Smokers also have higher risks of developing peptic ulcers and Crohn's disease than nonsmokers

17. Alcohol interferes with acid secretion, stomach muscles, and nutrient absorption. Too many drinks can contribute to heartburn, diarrhea, liver problems, esophageal and gastric cancer

18. Heartburn Remedies: Antacids For occasional heartburn, should take something that works immediately, like a liquid antacid. An antacid neutralizes stomach acid. This provides temporary relief from heartburn, and is emptied from the stomach quickly. It's important to follow the directions carefully, because the overuse of antacids can cause serious side effects. And with more prolonged heartburn symptom, antacids may not help.

19. Antacids absorbed in Sodium bicarbonate Calcii carbonate nonabsorbed: 1 st generation – (Al): Phosphalugel Compensan 2 nd generation - (Al, Mg): Almagel, Maalox 3 rd generation - (Al, Mg + alginate): Gaviscon, Topalcan

20. Heartburn Remedies: Antacids They are also occasionally prescribed to help relieve the pain of ulcers. Some antacids also contain simethicone, an ingredient that helps eliminate excess gas. Some antacids contain magnesium or sodium bicarbonate, ingredients that may have a laxative effect. Side effects include constipation, diarrhea, white or pale bowel movements, and stomach cramps. Serious side effects can occur with an overdose or overuse of antacids.

21. ANTACIDS. GUIDELINES it is impossible to combine antacids with de-nol and sucralfate (pharmacodynamic incompatibility) all antacids are accepted only perorally - in case of occurring of heartburn or in 1 hour after-meal at the prolonged reception of antacids there is propensity to the infections of gastrointestinal way as a result of decline of protective role of hydrochloric acid

22. ANTACIDS. GUIDELINES (cont’d) To the patients with hypertensive disease, cardiac and kidney insufficiency, liver cirrhosis antacids, containing sodium bicarbonate, are contra-indicated. As a result of chemical reaction with muriatic acid they form chlorous sodium which is well absorbed in and causes the delay of water in an organism Absorbed antacids in large doses can cause system metabolic reactions - alkalosis

23. Heartburn Remedies: H2 Blockers Also available over-the- counter, H2 blockers work differently than antacids. Rather than zapping acids after they appear, these medications lower the production of stomach acid. This can help prevent heartburn from acid reflux if taken about 30 minutes before meals. More powerful doses are available in prescription form.

24. H2 Blockers 1 st generation (cimetidine) 2 nd generation (ranitidine) 3 rd generation (famotidine)

25. H2 blockers They can be taken at bedtime to suppress nighttime production of acid. Available both over- the-counter and as prescriptions, H2 blockers help about half of heartburn sufferers. Brands include Axid, Pepcid AC, Tagamet HB, and Zantac 75

26. H2 blockers Possible serious side effects include confusion, chest tightness, bleeding, sore throat, fever, irregular heartbeat, weakness, and unusual fatigue. Other, less serious side effects include headache, dizziness, and diarrhea. These are usually temporary and will likely go away on their own. When combined with lifestyle changes, these over-the- counter remedies relieve symptoms in about 25% of heartburn sufferers. People who have more severe heartburn symptoms that aren't relieved with these medications or who have been using these drugs for more than two weeks should contact their physician.

28. Acid Blockers: Proton Pump Inhibitors Proton pump inhibitors, available over-the- counter and by prescription, are a class of drugs that block the production of stomach acid. They are more effective at decreasing acid production than H2 blockers. Brands include Aciphex, Nexium, Prevacid, Prilosec, Protonix, and Zegerid.

31. Promotility agents The drug Reglan speeds up the digestion process and decreases the amount of stomach acid that splashes back into the esophagus.

32. Which Heartburn Medication to Take? The heartburn treatment that's best for the patient depends on many things. How often does heartburn happen? How bad is it? Does the patient want fast relief or prevention? Antacids offer fast relief for mild heartburn. H2 blockers can stop the burn before it starts, but only if you know when to take them. Proton pump inhibitors can tackle really stubborn heartburn.

33. Hierarchy of efficacy for drug treatments (most effective first) High dose proton pump inhibitors Standard dose proton pump inhibitors Half dose proton pump inhibitors Standard dose H2-receptor antagonists Antacids

34. Long term safety and tolerability have been extensively documented for H2 receptor antagonists and proton pump inhibitors Cisapride has similar effectiveness to standard dose H2 receptor antagonists but is inferior to standard dose omeprazole.

35. There are two approaches to the initial medical treatment Treatment can either start with the most effective regimen and subsequently be stepped down or start with the minimum intervention and be stepped up. The higher initial drug cost when beginning with the most effective regimen is likely to be offset by rapid symptom control, which is a substantial benefit to the patient and reduces the need for repeated consultation. It is recommend starting with the most effective treatment, which is currently standard dose of a proton pump inhibitor. This treatment is also the preferred choice for empirical therapy.

36. After the initial treatment, it is worth trying a period without treatment because some patients will not need further medical intervention, at least for several months. Patients in whom symptoms immediately recur require longer term management.

37. Strategies for long term management Most patients with gastro-oesophageal reflux disease require long term management. The guiding principle for long term management is to step down to the treatment that is least costly but still effective in controlling symptoms, The rationale for this approach is minimisation of cost, although relative drug costs will vary across practice settings, and decreasing efficacy does not always mean decreasing cost. Finding the right level of management may take time in some patients.

38. For patients who require only intermittent short courses of antisecretory therapy, it may be more effective to give a proton pump inhibitor at full dose than to titrate treatment up from either half dose of proton pump inhibitor or standard dose of a H2 receptor antagonist.

39. Tegaserod, a 5-HT4-receptor partial agonist, effectively treats irritable bowel syndrome with constipation. Tegaserod improved the esophageal pain threshold to mechanical distention, and distressing upper-GI symptoms in patients with functional heartburn.