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Management of reflux in primary care is not always straightforward. Patients presenting with symptoms often have various needs, making it difficult to:

  • Know when to refer them for further testing, e.g. endoscopy
  • Achieve an accurate diagnosis
  • Understand their therapy needs

Here these challenges are explored in greater detail to help you effectively manage your reflux patients.

When to refer your patients

Knowing when to refer your patients for diagnostic testing or further opinion is crucial for effective reflux management. Most patients do not require referral; however, identifying those who do can be difficult. The table below details when you should consider referral for either endoscopy or secondary opinion.

Endoscopy Secondary opinion
Emergency cases (e.g. acute upper GI bleed) Refractory to treatment
Patients who do not respond to treatment For consideration of antireflux surgery
Patient request (i.e. to alleviate patient anxiety)  
Patients at a higher risk of Barrett’s oesophagus (e.g. white, male, overweight, excessive alcohol consumption)  

Referral for endoscopy is not indicated if a patient responds to their PPIs but symptoms recur on stopping therapy. These patients have responded to treatment and the right course is to restart the PPI and begin to wean them off gradually with lower doses and add alginate support. It is important to remember that alginates should be taken on a regular basis after meals for 3–4 weeks.

Annual reviews

A medication review should be conducted for any patient on long-term treatment. This should aim to:

  • Identify potential changes in the patient
  • Check the clinical efficacy of the medication
  • Ensure they are taking the medication appropriately
  • Explore their use of other medications (e.g. over-the-counter alginates)

Annual reviews are important for many patients on long-term proton pump inhibitors (PPIs); however, they are often difficult to achieve. It is important these are prioritised in your patients to:

  • Analyse the effectiveness of patient therapy
  • Ensure they are maintained on the lowest effective dose
  • Consider stepping them down and stopping PPIs if appropriate (it is important to remember that PPIs should not be stopped in the cases of severe oesophagitis or Barrett’s oesophagus)

Differential diagnosis: When it is not reflux

Complications can arise when patients present with typical reflux symptoms that do not respond to treatment, i.e. refractory patients. This can indicate the presence of other conditions, such as eosinophilic oesophagitis, functional heartburn, cardiac complications, musculoskeletal problems, etc. These patients often require a secondary referral and further investigation.

To help alleviate this problem, ensure you:

  • Take an accurate history
    It is important to note down the exact symptoms experienced. Often, patients can misinterpret their experience, identifying chest pain or dysphagia as heartburn. This can lead to incorrect diagnoses. Taking an accurate history of all symptoms experienced will help with differential diagnosis.
  • Avoid the use of ‘dyspepsia’
    The term ‘dyspepsia’ can be used to explain a number of conditions that affect the upper GI tract. Using an overarching term to refer to a range of GI symptoms can complicate diagnosis. Dyspepsia itself can be broken down into the following categories:
    • Reflux type (i.e. heartburn and regurgitation)
    • Ulcer type (i.e. epigastric pain)
    • Dysmotility type (i.e. nausea, bloating and fullness)
    In order to improve differential diagnosis, avoid the use of ‘dyspepsia’, and instead report the exact condition and patient symptoms.

How to manage patient self-care

Recent CCG guidance has recommended a reduction in the prescription of over-the-counter (OTC) medications. As most antireflux therapies can be either prescribed or bought OTC, this guidance can have severe repercussions for your reflux patients.

Here are some quick tips from our experts to ensure your reflux patients receive the support and care they require in light of this guidance.

  1. Advise your patient on how to take the medication correctly
    Most patients using OTC therapies do not follow instructions strictly. If you are recommending OTC therapies, you should ensure your patients understand how to appropriately take the medication. For example, sporadic use of alginates is often ineffective when managing patients with reflux. Therefore, ensure you emphasise the importance of taking alginates regularly after meals and before bedtime. Prescribing medications can sometimes be the best way to get this message across. Despite this recent guidance, use of prescriptions to ensure your patients are effectively using their therapies can be valuable.
  2. Ensure your patients are not stepped up unnecessarily
    Stepping patients up onto higher doses or new therapies is not always necessary. Although guidance has recommended avoiding prescriptions of OTC products, it can be beneficial to first prescribe these therapies before considering stepping up your patient’s treatment. With reflux, it is advisable to first prescribe alginates before considering PPIs. This may help reduce long-term reliance on PPI treatment.
  3. Do not restrict OTC prescriptions in complex patients
    For some patients, it can be essential to prescribe OTC therapies, regardless of guidance from CCGs. If prescription of OTC products is the most effective therapy for your patient, then this should be provided to them

This content hub is funded by RB. The view and opinions presented here represent those of the doctors and do not reflect those of RB.

Date of preparation: February 2019

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