INTRODUCTION

Many digestive conditions are commonly experienced by patients and may be self-treated appropriately. Consumers are motivated and frequently use self-care to manage their health. Pharmacy personnel need only to reflect on the type and frequency of questions that they may experience during a typical day at the pharmacy. Research published by the Consumer Healthcare Products Association (CHPA) reveals 93% of adults prefer to treat minor ailments with nonprescription or over-the-counter (OTC) medications before seeking professional care, and 96% of consumers believe OTC medications make it easy to care for minor medical ailments.¹ Additionally, 89% of consumers and 87% of physicians believe that use of OTC medications is an important part of overall and family health care.¹

On average, households in the United States (US) spend about $442 annually on OTC products.² Overall US spending on OTC products reached $36.5 billion in 2020.³ Spending on heartburn medications was $2,121 million, multi-symptom gastrointestinal (GI) medications was $321 million, and gas relief medications was $179 million in 2020.³ Accessibility to the pharmacy team and their knowledge of OTC medications for common digestive issues allows consumers to engage in appropriate self-care and save health care costs. On average, every dollar spent by consumers on OTC medicines saves $6 to $7 for the US health care system as a whole.⁴

DIGESTIVE HEALTH

Good digestive health habits can help prevent issues such as heartburn, gastroesophageal reflux disease (GERD), and other GI problems. A balanced diet with adequate fiber and sufficient fluid intake, while avoiding excessive alcohol intake and late-night eating, can contribute to good digestive health. Among consumers, digestive/gut health is one of the hottest wellness focuses.⁵ During the pandemic, consumers learned more about the connection between good digestive health and immunity, increased metabolism, and reduced stress/anxiety. They are increasingly including plants, fermented foods and beverages, and spices (eg, ginger, curcumin) in their diets, according to recent research. Dollar sales for plant-based foods and beverages were up 34% in 2020 versus 2019, as were the number of people buying them, up from 49% in 2019 to 54% in 2020. Most of the sales increase was for the purchase of nut-based milks (eg, almond, coconut), and plant-based meat alternatives that consumers are buying for health and sustainability reasons (52% and 38% of those surveyed, respectively).⁵

The US Department of Agriculture (USDA) publishes scientifically-based dietary guidelines every 5 years. The latest publication outlines dietary guidelines by life stage, from birth through older adulthood and may be downloaded at www.dietaryguidelines.gov.⁶ The Secretaries of the USDA and US Department of Health and Human Services (HHS) introductory message to the new guidelines emphasize that beyond the science must come practice, “that is, making food and beverage choices that align with the Dietary Guidelines.” Their hope is that consumers can begin with the new “Start Simple” app and make modest daily changes to their diet toward an improved healthy routine over time. The guidelines are a good tool for pharmacists and pharmacy technicians to have on hand to answer questions from patients.⁶

A more user-friendly tool created by the USDA is www.MyPlate.gov with information for both health professionals and consumers, including links to download the Start Simple mobile app and the dietary guidelines.⁶ The MyPlate website focuses on the 5 food groups (ie, fruits, vegetables, grains, protein foods, dairy), how much should be on each plate, and how that may change by age. The MyPlate website also provides tools in addition to the app including quizzes, planning tools, resources, and a MyPlate Kitchen with recipes. It is a great website for patient referral.

HEARTBURN AND GERD

Heartburn and GERD are common conditions that occur in the GI tract. Heartburn is a burning sensation that arises from the substernal (breastbone) or epigastric area and moves toward the neck or arms. Most people experience mild, infrequent, episodic heartburn caused by their diet or lifestyle. Others may experience more frequent heartburn, occurring 2 or more days per week. Frequent, persistent heartburn for 3 or more months is the most common symptom of GERD.⁷ TABLE 1 summarizes heartburn and GERD classification.⁷

Heartburn may be experienced postprandially within 2 hours of eating. It also may occur when bending over or lying down. Some individuals experience nocturnal heartburn after going to sleep, and the condition may wake them during the night.⁷ Patients often describe heartburn as indigestion, reflux, or sour stomach.⁷ Similar symptoms can occur with dyspepsia or more serious GI issues, which is why it is important to assess patients to identify when referral for further follow up should be made. Dyspepsia is pain and/or discomfort in the upper middle part of the stomach.⁸ Symptoms may include a gnawing or burning stomach pain, bloating, heartburn, nausea, vomiting, and burping.Stomach ulcers and reflux can cause dyspepsia, but its cause can often not be identified.⁸

Most children younger than 12 years of age with GERD, and some adults, may have GERD without heartburn. Other symptoms may include a dry cough, asthma, pain or trouble swallowing (dysphagia and odynophagia), or GI bleeding.⁹ Dysphagia and odynophagia are a result of complications of GERD, such as erosive or ulcerative esophagitis, esophageal stricture, or cancer. GERD pain can mimic cardiac arrest by radiating to the back, neck, jaw, or arms. However, severe, crushing chest pain, especially if the patient has nausea or is vomiting, has shortness of breath, or is sweating, may indicate a heart attack, and emergency medical treatment should be sought.⁷

Heartburn, GERD, and dyspepsia can lead to increased morbidity, complications, and costs. For example, patients with GERD often experience esophageal damage from the acidic stomach contents refluxing into the esophagus.⁷ For those experiencing nocturnal heartburn or GERD symptoms, sleep quality may be impacted, causing poor functioning in the daytime. Patients with GERD symptoms miss on average 2 hours of work weekly because of their symptoms.⁷ In 2015, costs associated with esophageal disorders were $18.1 billion and just over half of that expense was for prescription medicines.¹⁰ More than a third of adults in the US may experience acid reflux weekly.¹¹ It is more common among pregnant women.⁷ The American College of Gastroenterology (ACG) estimates 20% of the population may have GERD,¹² and its prevalence has been increasing the last 30 years.⁷  The prevalence of dyspepsia varies based upon how it is defined, and is 5% to 15% when heartburn is excluded.⁷

Common Causes of Heartburn and GERD

Heartburn can be caused by diet or physiological factors. Eating foods with chocolate, citrus, or tomato-based products, as well as spicy, high-fat, or high-sugar foods, can cause the lower esophageal sphincter (LES) to relax, allowing acid to reflux. Other contributing factors include caffeine-containing and carbonated beverages, nicotine, and alcohol.⁹ In addition, some medications can cause heartburn by reducing LES pressure or through direct irritation. Those that reduce LES pressure include^7,13:

• Anticholinergic drugs (antihistamines)
• Beta-2 agonists (bronchodilators)
• Calcium channel blockers
• Benzodiazepines
• Nitrates (for angina)
• Opioid analgesics
• Theophylline
• Caffeine
• Tricyclic antidepressants.^7,13

Medications that may irritate the GI tract directly include aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), iron, potassium, bisphosphonates for osteoporosis, antibiotics (clindamycin, doxycycline, tetracycline), prednisone, and chemotherapy.¹³ Some diseases can contribute to heartburn, including motility disorders, scleroderma, peptic ulcer disease, and Zollinger-Ellison syndrome.⁷

Assessment

Questions that should be asked when assessing patients who complain of heartburn include:

• What symptoms are you experiencing?
• How often do you have these symptoms?
• When do your symptoms occur?
• Do these symptoms usually occur after eating something specific?
• What are your typical dietary habits? (eg, spicy foods, caffeine)
• Does anything make your symptoms feel better? Worse? Have you tried anything?

The patient’s medication history should be reviewed to see if it includes any medicines that may cause heartburn. The frequency and symptoms experienced may point to heartburn or GERD. If a patient complains of burning, gnawing pain that goes away upon eating and comes and goes for periods, he or she may have a duodenal ulcer and should be referred to a physician for treatment.⁷ Gastric ulcer pain is associated with pain that occurs anytime throughout the day, but often occurs immediately or within 3 hours of eating. Vomiting blood or blood in the stool also may indicate peptic ulcer disease. In all cases, patients should be referred to their physician or other health care provider for follow-up.⁷

Other exclusions for self-treatment of heartburn include^7,9,14:

• Frequent heartburn for more than 3 months
• Heartburn while taking recommended dosages of OTC or prescription histamine-2 receptor antagonists (H2RAs) or proton pump inhibitors (PPIs)
• Heartburn that continues after 2 weeks of treatment with OTC H2RAs or PPIs
• Severe heartburn and dyspepsia
• Nocturnal heartburn
• Pain or difficulty swallowing solid foods
• Vomiting blood or black material or passing bloody stools
• Chronic hoarseness, wheezing, or coughing
• Unexplained weight loss
• Continuous nausea, vomiting, or diarrhea
• Chest pain with sweating, pain radiating to the shoulder, neck, arm, or jaw, and shortness of breath
• Children younger than 2 years (antacids), 12 years (H2RAs), or 18 years (PPIs).^{7,9, 14}

TREATMENT OF HEARTBURN

Treatment goals for heartburn are to alleviate or eliminate the patient’s symptoms, reduce the frequency and severity of symptoms, promote healing of esophageal tissue, and prevent and manage unwanted medication effects.⁷ Both nonpharmacologic and pharmacologic options may benefit patients with heartburn.

Patient assessment will allow the pharmacist to determine if the patient is a candidate for self-treatment. Patients who are not candidates for self-treatment should be referred for further follow up.

Nonpharmacologic Treatments (Lifestyle Interventions)

Nonpharmacologic interventions that may be recommended include⁹:

• Stopping or reducing smoking
• Avoiding foods, beverages, and activities that worsen symptoms
• Eating small, frequent meals
• Following a Mediterranean diet (low in red/processed meat, high in fruits, vegetables, whole grains, fish) reduces risk of GERD¹⁵
• Losing weight, if needed, and if the patient is not pregnant
• Wearing loose-fitting clothes
• Avoiding lying down or going to bed for 3 hours after a meal
• Raising the head of the patient’s bed 6 to 8 inches by securing wood blocks under the bedposts or using a foam pillow pad for nocturnal heartburn sufferers.⁹

A trigger diary can be a useful tool for patients to help determine what beverages, foods, or activities are associated with the onset of heartburn and its severity.¹² By keeping track of what causes heartburn, patients can identify the triggers and remove them from the diet and avoid activities that lead to heartburn. A review of a patient’s medication profile and their use of OTC medications can help identify any medications that may contribute to heartburn.

Pharmacologic Treatments

Pharmacologic treatment options for heartburn include antacids, H2RAs, and PPIs. TABLE 2 provides a list of select OTC heartburn products.

Antacids

Antacids provide rapid symptom relief, lasting 15 minutes to 2 hours if taken with food.⁷ Many antacids also contain the anti-gas agent simethicone. Another combination is magnesium carbonate and alginic acid, which together form a foam barrier that floats atop stomach acid, helping protect the esophageal mucosa from stomach acid during reflux episodes.^7,9 Many drug interactions occur with antacids because they can bind other medications or inhibit absorption of those medications by raising stomach pH.⁷ Most interactions can be avoided if antacids are taken at least 2 hours apart from other medications.¹⁶ Dosages can be repeated in 1 to 2 hours if needed, but should not exceed a product’s recommended dose. For patients using effervescent tablets, the pharmacist should advise them to allow the tablet to dissolve completely in water and allow the bubbles to subside before consumption. If antacids have to be used more than twice a week or regularly for 2 weeks or more, patients should be reassessed, with treatment changed to an H2RA or a PPI.⁷

H2RAs

There are 3 H2RAs available OTC for the treatment of heartburn: cimetidine (Tagamet), famotidine (Pepcid), and nizatidine (Axid). A fourth H2RA, ranitidine (Zantac), was withdrawn from the US market in April 2020 because of the presence of N-nitrosodimethylamine (NDMA), a probable human cancer-causing substance.¹⁷ The H2RAs are considered interchangeable despite some differences in duration of action, adverse effects, and drug interactions.⁷ Cimetidine is slightly shorter-acting and side effects include a weak antiandrogenic effect that may cause gynecomastia and impotence in men.¹⁸ Cimetidine, and ranitidine to a lesser extent, are inhibitors of most major cytochrome P450 (CYP450) enzymes, leading to decreased elimination of many drugs, including theophylline, warfarin, and phenytoin.¹⁶  Famotidine is not metabolized by the CYP450 system. Other interactions occur with drugs that require an acidic environment for absorption. These include some antifungals (eg, ketoconazole), protease inhibitors (eg, atazanavir), and iron salts.⁷

The most common adverse effects experienced with the H2RAs are headache, dizziness, constipation, and diarrhea.¹⁸ There are combination antacid/H2RA products available that provide rapid and ongoing relief and may be considered by patients if their heartburn is refractory to either agent alone. H2RAs should be used for mild to moderate, infrequent heartburn where a longer duration of effect than that of antacids is needed. Patients should be advised to take H2RAs at the onset of symptoms or 1 hour before meals. They should take them with a full glass of water unless they are using chewable famotidine.⁷

PPIs

PPIs available OTC for the self-treatment of heartburn include omeprazole (Prilosec OTC), esomeprazole (Nexium 24HR), and lansoprazole (Prevacid 24HR).¹⁸ They are indicated for the treatment of mild-to-moderate heartburn that occurs more than 2 days per week. PPIs work by reducing acid secretion by inhibiting the GI tract’s proton pump system. These medications may increase the risk of GI infections.¹⁸

PPIs may interact with other drugs metabolized by the CYP2C19 pathway, including diazepam, phenytoin, and warfarin.¹⁸ Patients taking clopidogrel (Plavix) should be advised not to take PPIs, or consult their medical provider, because PPIs can reduce clopidogrel’s clotting effect by up to 50%. PPIs also reduce the effect of protease inhibitors. PPIs have been associated with Clostridium difficile–associated diarrhea. The FDA requires additional labeling information on OTC PPI products instructing users to stop use and contact a health care provider if diarrhea occurs.¹⁸ A statistically significant association between PPI use and C difficile–associated diarrhea has emerged in the literature. Stomach acidity has been shown to be lethal to C difficile and its toxin.¹⁹ The most common adverse events reported with PPIs include headache, abdominal pain, nausea, diarrhea, and flatulence.¹⁸

Patients should be advised to take the PPIs once daily for 14 days, swallowed whole with a glass of water 30 to 60 minutes before a meal.¹⁸ Treatment may be repeated once in a 4-month period. The pharmacist should let the patient know that it may take 1 to 4 days for the medication to take effect. For some patients, relief of symptoms after a 2-week trial therapy with a PPI may be an indication that GERD is the cause of their GI problem.⁷ OTC PPIs are not approved for use in children younger than 18 years of age. In children older than 2 years, there are children’s antacid formulas that contain calcium carbonate for heartburn relief.¹⁸ H2RAs are labeled for use in children 12 years and older.¹⁸

Special Populations

For older patients, many may take medications that may cause heartburn. Because of decreased kidney and liver function, older patients may experience more adverse effects from medications. Because of decreased kidney function, antacids that contain aluminum and/or magnesium should be avoided.⁷ The 2019 American Geriatrics Society (AGS) Beers Criteria for potentially inappropriate medication use in older adults recommends avoiding H2RAs because of their potential to cause delirium or make it worse.²⁰ PPIs may be used for a 2-week course of therapy.⁷

Nonpharmacologic options should be recommended for women who are pregnant or breastfeeding.⁷ Overall calcium intake needs to be considered if antacids are used during pregnancy, as the upper daily limit for calcium in pregnant women is 2500 mg.²¹ H2RAs may be used in pregnancy.¹⁸ A meta-analysis of H2RA and PPI use in pregnancy suggested an association with childhood asthma.²² If heartburn is more frequent or severe, referral should be made for further evaluation.

COUNSELING TIPS

Advising patients about lifestyle changes that may reduce the occurrence and frequency of heartburn is important. The pharmacist may recommend that the patient keep a diary to note any heartburn triggers.¹² It is important to help the patient select the most appropriate product for self-treatment and explain each product’s advantages and disadvantages. The pharmacist also should discuss how to take any OTC products recommended, their usual dosage, the time expected for relief, possible side effects, and how to store the medication. Class-specific instructions should be provided as noted in the treatment section. The pharmacist also should explain to patients when to seek further treatment from their physician, including if symptoms persist or do not improve within 2 weeks of self-treatment.⁷

Pharmacy technicians should know the location of antacids, H2RAs, and PPIs within the pharmacy and be able to help patients find the appropriate product. They should also be able to show patients the product label and directions for use. When a pharmacist recommendation is required, the pharmacy technician should look up the patient’s medication profile, if available, for the pharmacist to review prior to product selection.

LACTOSE INTOLERANCE

Lactose intolerance is the inability or insufficient ability to digest lactose, a sugar found in milk and milk products. The condition is caused by a deficiency of the enzyme lactase, which is produced by the cells lining the small intestine. Lactase breaks down lactose into 2 simpler forms of sugar called glucose and galactose, which then are absorbed into the bloodstream.²³ Lactase deficiency can be categorized into three main types²⁴:

• Primary adult lactase deficiency (primary hypolactasia)
• Secondary (acquired) hypolactasia
• Congenital alactasia (lifelong complete absence of lactase).²⁴

Primary lactase deficiency develops over time because the body decreases production of lactase as a person ages. The condition begins after 2 years of age, when less lactase is produced by the body. Most children who have lactase deficiency do not experience symptoms of lactose intolerance until late adolescence or adulthood. There may be a possible genetic link to primary lactase deficiency.^{23, 24}

Secondary lactase deficiency results from injury to the small intestine that occurs with severe diarrheal illness, celiac disease, Crohn’s disease, HIV infection, enteropathy, chemotherapy, or radiation. This type of lactase deficiency can occur at any age but is more common in infancy.²⁴ Congenital lactase deficiency, the lifelong complete absence of lactase, is a rare disorder that appears to run in families. Infants begin to have symptoms of bloating and watery diarrhea shortly after starting on breast milk or formula feeding.^25,26 They typically do not gain weight and are dehydrated. The condition is most often found in Scandinavian countries.

About 36% of people in the US have issues with lactose digestion.²⁴ Lactose intolerance is more common in Asian Americans and African Americans than in White Americans and northern Europeans.²⁴

Signs and Symptoms

People with lactase deficiency often cannot digest milk or other dairy products that contain lactose. Dairy products such as dry milk powder, whey, curds, and milk solids also are common ingredients in processed foods, including²⁷:

• Baked goods, including bread
• Baking mixes for pancakes, cookies, and cakes
• Candy
• Cereals
• Instant soups and drinks
• Lunch meat
• Margarine and salad dressings
• Processed breakfast foods, such as doughnuts, frozen waffles and pancakes, toaster pastries, and sweet rolls
• Processed breakfast cereals
• Potato chips, corn chips, and other processed snacks
• Liquid and powder milk-based meal replacements
• Protein powders and bars
• Nondairy liquid and powder coffee creamers
• Nondairy whipped toppings.²⁷

Lactose also may be found in both OTC and prescription medicines, including antacids and oral contraceptives.²⁷

When lactase is deficient or absent, unabsorbed lactose attracts fluid through osmosis into the bowel, increasing GI content volume and fluidity. Unabsorbed lactose that enters the colon results in bacterial fermentation into monosaccharides, which are not absorbed. This causes more fluid to be drawn into the colon by osmosis. The result is excess fluid and gas in the bowel.²⁵ Common symptoms of lactose intolerance result, which include abdominal bloating and cramps, diarrhea, gas, and nausea. Symptoms generally occur 30 minutes to 2 hours after ingesting lactose.²⁵ Infants with congenital lactase deficiency may be dehydrated or irritable, vomit, have watery stools, and show failure to thrive.

Patient Assessment

Diagnosis of lactose intolerance may involve several tests²⁸:

• Lactose tolerance test, which measures blood levels of glucose after a person has had a drink containing lactose
• Hydrogen breath test, which can detect increased levels of hydrogen gas produced by fermentation of lactose in the intestines and excreted through the lungs
• Stool acidity test, which measures acids found in the stool when the lactose is not digested.²⁸

Often such tests are not required. If lactose intolerance is suspected, then milk and milk products can be eliminated from the diet for a period of time. If the symptoms go away, then lactose-containing foods should be added back into the diet to be sure that lactose was the cause.²⁸

One simple 2-day test that the pharmacist might recommend to patients experiencing problems is not to eat anything after 10 pm on the evening before the test.²⁹ The next morning, advise the patient to eat a normal breakfast and include a 12-ounce glass of regular milk of any kind. Have the patient keep track of any discomfort he or she experiences, including its intensity, for 6 hours. Advise the patient not to eat anything after 10 pm at the end of day 1. The morning of the second day, have the patient prepare the exact same breakfast as day 1. Then have the patient take a lactase enzyme product (TABLE 2) with the first bite of dairy food. Alternatively, have the patient drink a 12-ounce glass of lactose-free milk (any variety is fine) in place of the milk brand the patient had on day 1. Have the patient keep track of any discomfort he or she experiences, including its intensity, for 6 hours. If patients experience no discomfort on day 2 or much milder discomfort, it may indicate lactose intolerance.²⁹

Care should be taken, however, in self-diagnosing lactose intolerance, as its symptoms may be similar to other GI disorders, such as irritable bowel syndrome (IBS).²⁶ Expanding a 2-day test to a 3- to 4-week time period without lactose-containing products may be a good indicator. If a patient’s symptoms are not related to milk or dairy products, the pharmacist should refer the patient to a physician for follow-up.

Treatment Options for Lactose Intolerance

The primary treatment for lactose intolerance is avoiding foods that contain lactose, especially milk and milk products. This is especially true for infants and children. Older children and adults may be able to eat or drink limited amounts of lactose-containing foods.³⁰ Selected lactase enzyme products are listed in TABLE 3. Tablets and capsules are taken with the initial bite or drink of a food or liquid containing lactose. Liquid lactase may be added to milk to lower the lactose content before the person drinks it. Probiotics can help improve lactose digestion when taken daily. A 14-day trial is recommended for patients interested in using probiotics. If no benefit is seen, further use is not recommended.²⁶ Further, a wide variety of lactose-free milk, cottage cheese, ice cream, infant formulas, and other products are available. Other alternatives include soy products, if tolerated, and rice milk.

Patient Counseling

Dietary counseling can be helpful to an individual with lactose intolerance. The dietary plan should include foods high in calcium and vitamin D because milk and dairy products are a primary source of these important components of bone growth and repair.²⁷ Helping patients identify other calcium-rich sources of food can be an important activity for the pharmacist. These include rhubarb, oranges, spinach, lettuce greens, broccoli, salmon, sardines, tuna, soy milk, and pinto beans.²⁷ Carefully choosing foods and dietary supplements is important in reducing symptoms and ensuring health for patients with lactose intolerance.

SUMMARY

Digestive health issues represent commonly experienced problems that patients may wish to self-treat. The community pharmacy team is widely accessible to assist in locating and providing appropriate treatment recommendations to patients with common digestive issues, including heartburn, dyspepsia, and lactose intolerance. In addition, team members can provide information on diet and life-style modifications and their role in maintaining digestive health.

REFERENCES

1. Understanding trust in OTC medicines: consumer and healthcare provider perspectives. Consumer Healthcare Products Association (CHPA). March 6, 2013. Accessed September 8, 2021. https://www.chpa.org/about-consumer-healthcare/research-data/research-reports/understanding-trust-otc-medicines-consumer
2. The value of OTC medicines to the US healthcare system. CHPA. March 1, 2019. Accessed September 8, 2021. https://www.chpa.org/about-consumer-healthcare/research-data/research-reports/value-otc-medicines-us-healthcare-system-0
3. OTC use statistics. CHPA. Accessed September 8, 2021. https://www.chpa.org/about-consumer-healthcare/research-data/otc-use-statistics
4. The value of OTC medicine to the United States. CHPA. January 2012. Accessed September 8, 2021. https://www.chpa.org/sites/default/files/media/docs/2020-10/The-Value-OTC-Medicine-to-the-United-States-01012012.pdf
5. The evolution of self-care. CHPA. June 10, 2021. Accessed September 8, 2021. https://www.chpa.org/about-consumer-healthcare/research-data/research-reports/evolution-self-care
6. US Department of Agriculture and US Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. 9th ed. December 2020. Accessed September 8, 2021. https://www.dietaryguidelines.gov/sites/default/files/2021-03/Dietary_Guidelines_for_Americans-2020-2025.pdf
7. Whetsel T, Garofoli G. Chapter 13: Heartburn and dyspepsia. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 20th ed. American Pharmacists Association; 2020:253-270. https://doi.org/10.21019/9781582123172.ch13
8. Information from your family doctor. Dyspepsia: what it is and what to do about it. Am Fam Physician. 2010;82(12):1459-1460.
9. Symptoms and causes of GER and GERD. National Institute of Diabetes and Digestive and Kidney Diseases. June 2020. Accessed September 14, 2021. https://www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-adults/symptoms-causes
10. Peery AF, Crockett SD, Murphy CC, et al. Burden and cost of gastrointestinal, liver, pancreatic diseases in the United States: update 2018. 2019;156(1):254-272.
11. Delshad SD, Almario CV, Chey WD, et.al. Prevalence of gastroesophageal reflux disease and proton pump inhibitor-refractory symptoms. Gastroenterology. 2020;158(5):1250-1261.e2.
12. Acid reflux. Overview. How common is GERD? American College of Gastroenterology. Accessed September 14, 2021. https://gi.org/topics/acid-reflux/#tabs2
13. Gillson S. Common causes of heartburn. Verywell Health. June 25, 2021. Accessed September 14, 2021. https://www.verywellhealth.com/common-causes-of-heartburn-1741818
14. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108(3):308-328.
15. Sethi S, Richter JE. Diet and gastroesophageal reflux disease: role in pathogenesis and management. Curr Opin Gastroenterol. 2017;33(2):107-111.
16. Welage LS, Berardi RR. Drug interactions with antiulcer agents: considerations in the treatment of acid-peptic disease. J Pharm Pract. 1994;7(4):177-195.
17. US Food and Drug Administration (FDA). FDA requests removal of all ranitidine products (Zantac) from the market. April 1, 2020. Accessed September 18, 2021. https://www.fda.gov/news-events/press-announcements/fda-requests-removal-all-ranitidine-products-zantac-market
18. Lexicomp Version 6.7.2. 2021. UpToDate Inc. Wolters Kluwer. Accessed September 18, 2021.
19. Johnson DA, Katz PO, Armstrong D, et al. The safety of appropriate use of over-the-counter proton pump inhibitors: an evidence-based review and Delphi consensus. 2017;77(5):547-561.
20. 2019 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2019 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019;67(4):674-694.
21. Calcium: Fact sheet for health professionals. National Institutes of Health, Office of Dietary Supplements. August 17, 2021. Accessed September 19, 2021. https://ods.od.nih.gov/factsheets/Calcium-HealthProfessional/
22. Lai T, Wu M, Liu J, et al. Acid-suppressive drug use during pregnancy and the risk of childhood asthma: a meta-analysis. 2018;141(2):e20170889.
23. Lactose intolerance. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). February 2018. Accessed September 19, 2021. https://www.niddk.nih.gov/health-information/digestive-diseases/lactose-intolerance
24. Porto A. Lactose intolerance in infants and children: parent FAQs. American Academy of Pediatrics HealthyChildren.org website. September 29, 2016. Accessed October 31, 2021. https://www.healthychildren.org/English/healthy-living/nutrition/Pages/Lactose-Intolerance-in-Children.aspx
25. Symptoms and causes of lactose intolerance. NIDDK. February 2018. Accessed September 19, 2021. https://www.niddk.nih.gov/health-information/digestive-diseases/lactose-intolerance/symptoms-causes
26. Jackowski R, Poole T. Chapter 14: Intestinal gas. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 20th ed. American Pharmacists Association; 2020:271-284. https://doi.org/10.21019/9781582123172.ch14
27. Eating, diet, and nutrition for lactose intolerance. NIDDK. February 2018. Accessed September 19, 2021. https://www.niddk.nih.gov/health-information/digestive-diseases/lactose-intolerance/eating-diet-nutrition
28. Diagnosis of lactose intolerance. NIDDK. February 2018. Accessed September 19, 2021. https://www.niddk.nih.gov/health-information/digestive-diseases/lactose-intolerance/diagnosis
29. Lactose intolerance factsheet. Lactaid website. Accessed September 11, 2021. https://www.lactaid.com/sites/lactaid_us/files/g16ac-a1604-73-lac-wbg-brand_2sided.pdf
30. Treatment for lactose intolerance. NIDDK. February 2018. Accessed September 19, 2021. https://www.niddk.nih.gov/health-information/digestive-diseases/lactose-intolerance/treatment

Back to Top

« Return to Activity