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Breakthrough can sometimes occur in reflux patients who are being maintained on proton pump inhibitors (PPIs). These symptoms can occur in up to 40% of patients treated with PPIs and typically take the form of intermittent episodes of heartburn and regurgitation. When your patients experience these, they should be equipped to address these symptoms and reduce the effect they have on quality of life. Examine the patient case below to understand how you can manage this patient type in primary care.

Watch the below videos to hear first-hand accounts from patients experiencing breakthrough symptoms

Alison Driscoll Pip Hamilton Madeline James
  • About the patient

    Christina is 62 years old, recently retired, and has been maintained on PPI therapy for the past three months to manage her symptoms of reflux. In the last month, she has begun experiencing episodes of regurgitation and heartburn. These occur intermittently, particularly after she has eaten a large meal, and they have become increasingly troublesome.

  • Treatment goals

    When treating Christina, you should aim to reduce the frequency of her breakthrough symptoms to limit their effect on her quality of life.

  • Challenges faced

    1. Not an uncommon problem

      Ensure your patients understand that the experience of symptoms whilst on PPIs is not uncommon.

    2. Night-time reflux

      Making note of the time of day breakthrough symptoms are experienced can help inform the treatment method you wish to use. For example, patients who experience symptoms at night but have not changed their eating habits may not be effectively managed on a morning dose of PPIs. In these patients, an evening dose (30 minutes before the evening meal) can be prescribed.

    3. Not all patients are breakthrough

      Patients experiencing heartburn and regurgitation on PPI therapy can also include:

      1. Non-responders (do not respond to PPI therapy)
      2. Refractory patients (some reflux symptoms continue to occur on a regular basis despite PPI therapy)
      With breakthrough, the patient is predominately maintained on their PPI therapy, experiencing few, intermittent symptoms.

  • Consultation advice

    • Check PPI administration

      Your first step in the management of Christina’s breakthrough is to ensure she is taking her medication appropriately. PPIs must be taken 15–30 minutes before breakfast.

    • The time of day

      Be sure to investigate when the symptoms occur to inform the treatment method you should provide. For example, if the symptoms occur postprandially, alginate therapy can be effective, whereas if they occur at night, an evening PPI dose may be advised.

    • Prescribe regular alginate therapy

      As alginates function via a different mode of action (i.e. they have a mechanical function that reduces reflux of even non-acidic stomach contents), they can help address symptoms that are not maintained via PPIs. You should prescribe Christina regular alginate therapy, which should be taken after meals.

    • Manage patient expectations

      Ensure your patients understand that breakthrough symptoms are common. Managing Christina’s expectations at the start of her therapy will allow her to have effective control over her condition.

    • Lifestyle advice

      Lifestyle changes can play a significant role in reducing the experience of reflux symptoms. You can advise Christina to reduce the size of her meals to limit her experience of persistent heartburn.

  • Resources

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: October 2018

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