GROUP PROTOCOL FOR THE MANAGEMENT of HEARTBURN and ACID REFLUX Version 4 January 2014 RATIFYING COMMITTEE Drugs and Therapeutics Group DATE RATIFIED MAUP EXPIRES January 2017 EXECUTIVE SPONSOR Executive Director of Nursing MAUP ORIGINAL AUTHOR Ray Lyon Chief Pharmacist REVIEWED BY Gill Bull Pharmacy Technician KEY POLICY ISSUES: Key indication for the use of Gaviscon Advance and Peptac Liquid Staff eligible to work under the protocol If you require this document in an alternative format, ie easy read, large text, audio, Braille or a community language please contact the Pharmacy Team on 01243 623349.
GROUP PROTOCOL FOR THE MANAGEMENT OF HEARTBURN AND ACID REFLUX (Gaviscon Advance Liquid and Peptac Liquid) Version: 4 January 2014 Group Protocol drawn up by: Name Dr Fran Osborn John Rosser Ray Lyon Title Staff Grade Practitioner, OPMHS Service Manager, WAMHS Chief Pharmacist - Strategy Group Protocol authorised by: (on behalf of the Trust). Executive Medical Director Executive Director of Nursing Chief Pharmacist Tim Ojo Helen Greatorex Ray Lyon Appointed Practitioner in Charge (on behalf of the ward) Date Protocol agreed January 2014 Proposed review date January 2017 Date Protocol expires January 2017 Ward Protocol relates to
GROUP PROTOCOL FOR THE MANAGEMENT OF HEARTBURN 1. CLINICAL CONDITION 1.1 Clinical condition Symptoms of heartburn (i.e. burning sensation behind the sternum) and/or acid regurgitation, (acid reflux). 1.2 Inclusion Criteria Patients with the above symptoms who are otherwise well. Patients who usually self-administer at home for prophylactic symptomatic treatment of above symptoms. 1.3 Exclusion Criteria Patients under 12 years of age. Known sensitivity to Gaviscon Advance or Peptac Liquid. Patients with known hypernatraemia or moderate to severe cardiovascular disease. Gaviscon Advance Liquid contains 2.3mmol Na + per 5ml. Peptac Liquid contains 3.1mmol Na + per 5ml. 1.4 Action to be taken if patient is excluded from treatment under protocol Consult with ward Medical Officer 9.00 am 5.00 pm Monday to Friday. Contact duty Medical Officer out of hours if discomfort warrants. 1.5 Action to be taken if patient refuses treatment under protocol None. Discuss with ward Medical Officer within working hours if symptoms persist. 2. STAFF AND LOCATION 2.1 Location 2.2 Staff Inpatient units Trustwide. Qualified nursing staff that have been signed off as competent by the Appointed Practitioner in Charge of the ward following training and successful completion of the 'Key Aspects of Pharmacy' questionnaire for Gaviscon Advance / Peptac Liquid. 2.3 Continued Training Requirements. Not required unless changes to protocol
3 TREATMENT 3.1 Name of medicine Gaviscon Advance Liquid or Peptac Liquid (Suspension). 3.2 Legal status (POM, P or GSL) GSL (General sales list) 3.3 Dose or dose range and criteria for determining dose Or 5 10ml of Gaviscon Advance Liquid, after meals and/or at bedtime. 10-20ml of Peptac Liquid, after meals and/or at bedtime. 3.4 Method of route of administration Oral. 3.5 Frequency of administration Up to four times a day. Maximum period of continuous treatment is 48 hours without a medical review of the underlying symptoms. Caution If the client gets no symptomatic relief or an increase in severity, particularly if the patient has a history of an MI or angina, then refer to the Medical Officer. 3.6 Follow up treatment Ward staff to monitor for continued complaints of indigestion, heartburn or chest pain and refer to Medical Officer as necessary. Documented review by ward Medical Officer. Continued advice re diet, fluid intake etc. (as above). 3.7 Side effects and possible drug interactions Avoid administering at the same time as other drugs as may impair the absorption of some drugs. 3.8 Instruction on identifying and managing possible adverse outcomes Normal ward observations. If there is a decline in the patient s physical condition or the nurse suspects an adverse reaction, contact the ward Medical Officer or duty Medical Officer.
Document concerns. 3.9 Arrangement for referral to medical advice Contact ward Medical Officer in normal working hours. Contact duty Medical Officer outside working hours. 4. INFORMATION AND DOCUMENTATION 4.1 Advice (including written advice) to be given to client or carer before or after treatment. Provide advice to patient on a more appropriate diet. Consider raising the head of the bed. Advise the patient or carer to inform nursing staff if symptoms persist. Offer patient information leaflet on heartburn, (if appropriate). 4.2 Details of treatment records required Completion of MAUP section of patient s drug chart. Record entry in case notes. This should record the presence of heartburn, and that Gaviscon Advance or Peptac Liquid was administered in line with MAUP, (or equivalent statement). 5. MANAGEMENT AND MONITORING 5.1 Advisory group approving the protocol Drugs & Therapeutics Group. 5.2 Lines of accountability Clinical Service Managers. 5.3 Method to report any adverse drug reactions to the doctor Normal ward policy for communicating with the Medical Officer. 5.4 Audit Arrangements Pharmacy supervision. Clinical audit. 5.5 Review Date and by Whom Every three years by the Drugs and Therapeutics Group or earlier if significant new evidence or guidance on either of the products becomes available.
6. Staff authorized to work under the Group Protocol I have read the group protocol and agree to use it: - Nurses agreeing to and authorized to work under the protocol Appointed Practitioner in Charge assessing competence Name Signature Name Signature Date
KEY ASPECTS OF PHARMACY QUESTIONNAIRE (To be completed without access to the Protocol or drug text books, eg BNF.) Key aspects of pharmacy for Gaviscon Advance Liquid and Peptac Liquid Professional's name: Grade: 1. Symptoms/criteria under which the patient will be eligible for treatment under the Protocol 2. Forms and strengths available 3. Mode of action 4. Exclusion criteria Gaviscon Advance : Peptac : 5. Dose 6. Route of administration 7. What potentially significant side effects and drug interactions are there? 8. What written/verbal advice must be given to the patient/carer on the identification and management of significant potential side effects? I confirm that at the time of completion the answers provided showed an acceptable level knowledge. Name: Designation: Signature: Date:
Patient Information on Heartburn Heartburn is a discomfort or pain caused by the stomach contents regurgitating from the stomach up into the gullet (oesophagus). The oesophagus is not made to withstand acid and is thus irritated and inflamed when acid from the stomach refluxes into it. This is known as reflux oesophagitis. Symptoms The pain caused by the irritation of the oesophagus is a burning pain which you feel in the centre of the chest. There is often an associated awareness of acid and stomach contents in the back of the throat or mouth. Lying down or bending tend to increase the symptoms. Causes The whole of the intestinal tract is in the form of a tube with muscles in the wall which move the food along (peristalsis). At the bottom of the oesophagus the muscles encircling the tube work rather like a valve to stop food going backwards. This is not a perfect valve, but in some people works less well than others: Obesity leads to a higher pressure in the abdomen. Pregnancy causes a higher pressure in the abdomen and there is also evidence that the changing hormone levels cause relaxation of the muscle valve. Large amounts to eat or drink cause back pressure. In hiatus hernia, which is quite a common condition, the top part of the stomach pokes through the muscle which separates the chest from the abdomen (the diaphragm), and results in disruption of the valve mechanism. Smoking causes the valve to relax and also increases acid production. Treatment and prevention If you smoke, try to stop. If you are over weight, try to lose weight. Avoid eating just before bed and if taking any tablets wash them down with a glass of water to avoid them sticking in your oesophagus and slowly dissolving there. Consider raising the head of your bed (one tends to slip down off extra pillows and so blocks or bricks under the head end of the bed may be better). Small meals regularly are better than large meals infrequently. Avoid tight clothing around the waist. Avoid aspirin and other anti-inflammatory medications (NSAIDs) eg ibuprofen, except after consultation with your doctor. If you require this document in an alternative format, i.e. easy read, large text, audio, Braille or a community language please contact the Pharmacy Team on 01243 623349.
Treatment and prevention (continued) Antacids neutralise the acid in the stomach, and often one containing a seaweed product (alginate) is used, as this floats on the stomach contents tending to keep them down. Various medications cause reduced acid secretion. Some of these are available over the counter and others only on prescription. There are medications which encourage the movement of food in the right direction (better peristalsis) and better valve action at the upper end of the stomach. Very occasionally surgery is offered but is not undertaken lightly. Reviewed unchanged January 2014