268 lines
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268 lines
71 KiB
Plaintext
The post has just arrived and in it a very nice surprise, the discovery that Jacques Seguela, one-time adviser to President Mitterrand, now close confidant of President and Madame Sarkozy (indeed he intoduced them), and something of a legend in French political communications, has dedicated his latest book to little old moi. With apologies for the missing accents here and in the French bits of the long posting which follows - the dedication to 'Le Pouvoir dans la Peau' (Power in the skin) reads 'A Alastair Campbell, mon spin doctor prefere' (three missing accents in one word - mes excuses sinceres). So what did I do for this honour, you are asking? Well, perhaps the fact that he asked me to read his book, and write a 'postface' assessment both of his writing and of the issues he covers, and the fact that I said yes, has something to do with it. He says some blushmakingly kind things in his 'preface to the postface', which I will have to leave to French readers of the whole thing (published by Plon). But for the largely Anglophone visitors of this blog, I thought some of you might like to read the said 'postface' in English (apart from the bits where I quote direct from his book). I hope all those students who write asking for help with dissertations will find something quotable in it. Meanwhile I am off to Norway for a conference and a meeting with the Norwegian Labour Party. I'm looking forward to being in the country with the highest 'human development index' in the world, and which showed such a mature response to the recent massacre of Oslo and Utoya. Here is the postface to Le Pouvoir dans la Peau Jacques Seguela writes about political campaigns and communications not merely as an expert analyst, but as an experienced practitioner. Hence his latest book contains both insights worth heeding, but also enlivening tales of his own experience. He is observer and participant; outsider looking in, and insider looking out. There is much to look at, not least in France with a Presidential election looming, and the outcome far from easy to predict. We live in a world defined by the pace of change, and whilst the velocity of that change has not always impacted upon our political institutions, many of which would remain recognisable to figures of history, it most certainly has impacted upon political communications. As Seguela writes: ‘En 5 ans le monde de la communication a plus evolue que dans les cents dernieres annees. ' Google, Youtube, Twitter, Facebook have quickly entered our language and changed the way we communicate, live our private lives, do business, do politics. People do not believe politicians as much as they once did. Nor do they believe the media. So who do we believe? We believe each other. The power and the political potential of social networks flows from that reality. Though fiercely modern in their application, social networks in some ways take us back to the politics of the village square. They are an electronic word of mouth on a sometimes global scale. This has changed the way people interact with each other and with their politicians. My first campaign as spokesman and strategist for Tony Blair was in 1997, three years in the planning after he had become leader of the Opposition Labour Party. Some of the principles of strategy we applied back then would certainly apply to a modern day election. But their tactical execution almost certainly would not. Politicians and their strategists have to adapt to change as well as lead it. Seguela gives some interesting insights into those who have adapted well, and those who have done less well. He clearly adores former President Lula of Brazil and you can feel his yearning for a French leader who can somehow combine hard-headed strategy with human empathy in the same way as a man who left office with satisfaction ratings of 87percent. Seguela probably remains best known in political circles for his role advising Francois Mitterrand. Yet wheras I am 'tribal Labour', and could not imagine supporting a Conservative Party candidate in the UK, Seguela came out as a major supporter of Nicolas Sarkozy. I wonder if one of the reasons was not a frustration that large parts of the left in France remain eternally suspicious of modern communications techniques and styles which, frankly, no modern leader in a modern democracy can ignore. How he or she adapts to, or uses, them is up to them. But you cannot stand aside and imagine the world has not changed. If Lula is a star of this book, so too is Barack Obama. American elections are of enormous interest to all political campaign junkies, a category in which both Seguela and I would almost certainly qualify. Much is made of Obama's use of the internet, a relatively new phenomenon in historical terms and one the young Senator used brilliantly in his quest to become President. Yet though it was an accurate expression of his modernity, underpinning its use were some very old-fashioned campaign principles. He used it to turn supporters into activists who both gave funds and also took his campaign materials and ideas and ran their own campaigns for him. Somehow he managed to make one of the most professional, most disciplined and best funded campaigns in history look like an enormous act of democratic participation. It was less command and control - the model we certainly adopted in 1997 and 2001, Labour's two landslide victories, easing off a little for our third win in 2005 - than 'inspire and empower.' 'Yes we can' not 'yes I can'. His supporters were more than supporters. They were an active part of the campaign, and of the message. The key to this was something that had nothing to do with politicians and everything to do with science, technology and the internet. Ask me who has had the most influence on campaigns in recent times and I might be tempted to reply Tim Berners-Lee, the man credited with gifting the web to the world. Its implications have been far reaching in virtually all aspects of our lives, politics and political campaigns foremost. The new household brand names of the cyber era have not replaced good policy work, messaging and organisation. But they have become essential components of the execution of them in the campaign. Mainstream conventional media remains important and influential, not least because, bizarrely, in most democracies the broadcasters continue to let the press set their agenda for them. But a candidate who tries to stand against the tide of new media will be making a big mistake, and missing big opportunities. If it has changed so much in the last five years, how much more will it change in the next five years? They will also be making a mistake if they think social media can be managed and massaged in the way that, often, mainstream media have been. The key - on this I agree totally with Seguela - is authenticity. And that should be good news for authentic political leaders and an authenticity hungry public alike. The public tend to get to the point of an election. Seguela has an interesting account of the last UK election and in particular the first ever televised Leaders' Debates. Though I had worked on three campaigns for Tony Blair, I am sufficiently tribally Labour to have answered a call from his successor, Gordon Brown, to go back to help him for his first election campaign as leader in 2011. One of the roles I ended up playing was that of David Cameron in Brown's preparatory sessions for the TV debates. These debates mattered, that much was sure. Election planning for Blair, I had always been doubtful about the benefit of such debates in a Parliamentary democracy where our leaders meet each other week in week out in the crucible of the House of Commons. I was worried the media would make them all about themselves, and that the policy issues would be drowned out. So it proved. Yet in a way the public did get to the point they wanted to. They did not particularly want Labour back after 13 years in power. They did not particularly yearn for David Cameron and a Conservative Party unsure about its direction. So the third party leader emerged through the middle. Nick Clegg was judged the clear winner by the instant reactions of public and media alike. For a few days he seemed impregnable. Yet come the vote, he did not make a huge breakthrough. It was only because neither Labour nor the Tories could get over the line that Clegg ended up as deputy Prime Minister in a coalition government. The country had not been able to make its mind up, delivered a muddled result and asked the leaders to sort it out. The leader who came first and the leader who came third did a deal to do so. I think Seguela is too kind to Cameron. Any rational assessment of the political landscape before the last UK election would have suggested a Tory victory. Labour in power a long time; the economic crash; a Parliament dominated by a scandal involving MPs' expenses; Iraq back in the news because of the official Inquiry; Afghanistan not going well; the press even more strongly in favour of a Tory win than they had been for a Labour win in 1997, and vicious about Brown. Also the Tories had big money to spend on the campaign and Labour did not. Yet Cameron could not secure a majority. Why not? There is no simple answer. The wonder of democracy lies in millions of people having their own experiences, impressions and judgements before deciding how to cast their vote. But the strategist in me says the simple answer is that Cameron lacked real strategic clarity. I think Sequela would agree that for all the changes that technological and mediatic change has forced upon political campaigns, strategy remains the key. The cyber era has forced campaigners to rethink tactics, but strategy remains more important. He and I are clearly in agreement that John McCain's appointment of Sarah Palin as running mate, for example, was a tactical masterstroke, but a strategic catastrophe. Tactically, he excited his base, gave the media a new toy, and momentarily unnnerved his opponent. Strategically he blew a hole through the two central planks of his campaign - experience, and being different from George Bush. In putting tactics before strategy, he broke one of the golden rules of campaigning. Strategists like rules. We like points of principle to act as anchors. I like the rules in Seguela's Chapter 5. On vote pour une idee. Pas pour une ideologie. On vote pour soi. Pas pour son candidat. On vote pour un homme. Pas pour un parti. On vote pour le professionalisme. Pas pour l'amateurisme. On vote pour un projet pas pour le rejet. On vote pour le coeur. Pas pour le rancoeur. On vote pour le futur. Pas pour le passe. On vote pour le bcbg. Pas pour le bling bling. It is charmingly French that he illuminates the rule about voting for le couer pas pour le rancour to a tale of love and sex. 'Si votre femme vous trompe, ce n'est pas en couvrant d'insulte son amant que vous le reconquerez. Mais en lui redonnant envie de vous. La mecanique electorale est le meme, se faire elire c'est se faire preferer.' That may seem glib. But politics is a human business. It is about feelings as well as policies, emotion as well as reason. People often talk about their political leaders as though in a relationship with them. 'He's not listening ... Why on earth did he do that? ... I've gone off him ... Oh, I still like him deep down.' Political leaders sometimes talk of the people in the same way. How many times did I sit in the back of a car with Tony Blair, or fly over Britain in a ‘plane and he would look down and say 'God, I wish I knew what they were thinking ... Do they still like us?' Back at the time of our first landslide, talk of the country 'falling in love' with Blair was widespread. Today, the biggest accusations of betrayal against Blair will often come from those who 'fell in love' most deeply at the outset of his leadership. Perhaps this trend towards relationship politics is being exacerbated by the tendency towards younger leaders. Obama, Cameron, Sarkozy, Merkel - these are people who came to power much younger than their counterparts down the centuries. Seguela, a man of a certain age, remains fascinated by youth and its impact. The brand manager in him can barely disguise his glee that Coca Cola, the drink of the young trendy, is 130 years old. You can sense the excitement he felt on meeting the young Americans - not born when Seguela was advising Mitterrand - who had developed Obama's digital strategy and so helped deliver a mailing list of 13m people. The focus on youth also dominates his analysis of the political consequences of the economic crash whose impact runs through these pages, and offers some fascinating factoids - half of all Europeans are over 50, whilst three quarters of Algerians are under 25. There are as many people under 30 in China as in Russia, the US and Australia combined, and in India twice as many as in China. That too is a powerful force of global change, and will have its impact on Western politics of the future. As to what it all means for the next French elections, I don't know. But this book provides part of the backdrop, economic and political. It should make interesting reading for anyone involved in that campaign. Whilst clearly still of the view Sarkozy was and is the right choice for France, (though the polls at the time of writing indicate he is in a minority) he throws out ideas and challenges for right and left alike. As traditional lines are drawn, careful reading might provoke candidates and parties to see that they should always be looking to the next new ideas, not merely repackaging the last new, let alone the old. I was in Paris recently as a guest of the left think tank, Terra Nova, and met politicians, advisors, militants, experts, journalists and bloggers. I came away with some strong impressions. Firstly, virtually everyone told me that President Sarkozy was hugely unpopular, and his ratings as low as it was possible to go. Yet many of the same people told me he could still win. They know he relishes a campaign. They suspect he may have learned from some mistakes. Incumbency is a powerful weapon. A comeback is a powerful narrative. And they worried that with the President so unpopular, the economy sluggish, social issues raw, and the left in power in many parts of France, the PS should have been doing far better in the polls (to which, incidentally, French politicians and media pay far too much attention.) Of course this was pre selection of a PS candidate. Many of the Socialists agreed with my analysis that once they had chosen the candidate, they needed to unite behind that candidate, resist their historic predilection for factionalism, run a campaign that was fresh, energetic and based upon a programme totally focused on the future and one which addressed people's concerns. They agreed too that the PS could no longer look down its nose at communication, but had to see it not just as an essential element of campaigning, but a democratic duty at a time when people have so many pressures on their lives and living standards, and concerns about the world around them. But though they agreed with the analysis, some worried about the Party’s capacity to deliver upon it. The fear of another defeat ought to be enough, surely, to deliver on the first and essential part: unity. As someone on the progressive side of the political divide, I continue to think the French left's over intellectualisation of politics, its focus on never-ending debate instead of agreement around big points and unity behind one accepted leader remains a problem. I added that I felt the way was wide open for someone to come along and set out, with total honesty and clarity, the challenges ahead, the limitations of what one leader or one country can do, but explain the world and begin to shape direction. In other words, what I sensed behind the seeming confusion and rather disgruntled nature of French opinion was a real desire for leadership of a strategic rather than a tactical nature. There too, there were concerns, not least because of memories of the negative impact on Lionel Jospin’s campaign when he stated – truthfully – that the State could not do everything. I heard a lot about Marine Le Pen and certainly the polls tell a good story for the leader of the Front National. She has certainly shown she can mount a campaign and get the media to accept a sense of change. When even her enemies refer to as Marine, rather than the more toxic Le Pen, that is something of a success. But whenever I have heard her, I have not heard a powerful argument for the future of France. So France enters a fascinating period, where not one single person I met predicted the outcome of either first or second round without at least some doubt in their eyes. When things are so tight, communications can make the difference. It is not a dirty word. I don't agree with all of Seguela’s analysis. I don't accept that only four US presidents radically changed the country. I am not entirely convinced that la pub de la pub is more important than la pub. I am not sure that David Cameron's loss of a child had the political impact Seguela thinks it did. I think Brits will be also be surprised at the dominant role he gives in the Tory campaign to his colleague David Jones. I think he overstates how Sarkozy is seen in the world. I agree with him that we need to be cautious about the potential abuse of the internet which has no global governance or regulation to match, but I'm not sure I agree this risks being 'en bras arme de l'anarchie'. But it is a book full of understanding of some of the big themes and the small details required for a successful campaigning mindset. He is, as one would expect for someone who has been close to different leaders, clued up on the importance of good chemistry between leader and strategist. He understands the importance of body language as well as language. He knows the importance of emotion as well as reason. He understands how the web is changing politics. One of my favourite phrases is that 'life is on the record'. He has a different way of putting it. 'Le "off" n'existe plus desormais. Tout ce que vous direz pourra se retourner contre vous.' It is why the whole 'droit d'etre oublie' is emerging as a debate. How many of the young men and women today filling the web with pictures and confessions from their private lives may end up running for office one day, and regretting their openness? On verra. Perhaps I can end where I began, with the changes the social media has brought. At the last election Labour did not do poster campaigns. This was a shame. In previous campaigns we had had some brilliant posters. But under Gordon Brown, we had very little money for the campaign. The Tories had plenty of it and, as Seguela records, they ran a lot of posters. One of their most expensive billboard campaigns was of a giant photo of Cameron with an anti-Labour slogan 'we can't go on like this.' Someone noticed that the Tory leader's face had been airbrushed. This fact became the source of thousands of tweets. Then someone set up a website mydavidcameron.com where people could send their own, largely anti-Tory, versions of this poster. These were sent in in their thousands, and many were much better, wittier and more politically devastating than the original. I'll tell you when I knew they had wasted their money - when the newspapers carried photos of one giant poster site which had been defaced ... Cameron's hair had been replaced with a painted version of Elvis Presley's hair, and to the slogan 'we can't go on like this' had been added the words of one of Elvis' most famous songs ... 'with suspicious minds'. The combination of the internet and wit had reduced the political impact of a hugely expensive campaign to zero. That is my final thought as you begin to read Jacques Seguela’s account. It is a quote from a former colleague, Labour MP Hazel Blears ... 'Campaigning is like sex. If you're not enjoying it, you're not doing it properly.'Heartburn and acid regurgitation are the typical symptoms of gastroesophageal reflux. Despite the availability of several treatment options, antacids remain the mainstay treatment for gastroesophageal reflux-related symptoms based on their efficacy, safety, and over-the-counter availability. Antacids are generally recommended for adults and children at least 12 years old, and the FDA recommends antacids as the first-line treatment for heartburn in pregnancy. This narrative review summarizes the mechanism, features, and limitations related to different antacid ingredients and techniques available to study the acid neutralization and buffering capacity of antacid formulations. Using supporting clinical evidence for different antacid ingredients, it also discusses the importance of antacids as OTC medicines and first-line therapies for heartburn, particularly in the era of the COVID-19 pandemic, in which reliance on self-care has increased. The review will also assist pharmacists and other healthcare professionals in helping individuals with heartburn to make informed self-care decisions and educating them to ensure that antacids are used in an optimal, safe, and effective manner.
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Keywords: Antacid, heartburn, acid regurgitation, gastrointestinal reflux disease, acid-neutralizing technique, self-care
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Introduction
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Heartburn is an uncomfortable, burning feeling in the chest, behind the breastbone, or in the upper part of the abdomen that sometimes spreads to the throat. 1 It is specifically related to the reflux of gastric acid through the lower esophageal sphincter, which is a typical symptom of gastroesophageal reflux disease (GERD). Some patients with GERD might also present with atypical symptoms (e.g., epigastric fullness/pressure/pain, dyspepsia, nausea, bloating, belching) and extra-esophageal symptoms (chronic cough, bronchospasm, wheezing, hoarseness, sore throat, asthma, laryngitis, dental erosions). GERD has been classified into three stages based on the frequency of symptoms: stage I (≤3 episodes per week), stage II (>3 times per week), and stage III (daily symptoms). Symptoms are more commonly observed after meals, and they worsen in recumbent positions.
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Antacids comprise a major class of over-the-counter (OTC) medicines sold globally, and consumers with acid indigestion and heartburn spend billions of dollars on these non-prescription medications in search of relief. 2 Antacids provide symptomatic relief from heartburn, hyperacidity, acid indigestion, GERD and upset stomach associated with these conditions. 3 Antacids act by neutralizing excess hydrochloric acid (HCl) in gastric juice and inhibit the proteolytic enzyme pepsin. 4 An antacid that increases gastric pH from 1.5 to 3.5 can reduce the concentration of gastric acid by 100-fold. 5 A few studies reported that some antacids can be safely used during pregnancy owing to their local action rather than systemic effects.6,7
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The effectiveness of each antacid depends on its neutralizing and buffering capacity. Manufacturers of antacids often reformulate some products to improve their palatability and organoleptic properties for a better consumer experience. Thus, several antacid products are available in the market, each claiming a relative advantage over one another, baffling physicians and the public with choices. The decision to select an antacid can be made according to the acid-neutralizing capacity (ANC), which can differ significantly, but it is unfortunately not stated on product labels. 8 An antacid can also be selected by considering its buffering capacity to maintain gastric pH above 3.5 for a considerable duration. This narrative review provides background and context for the current understanding of antacids and their roles in treating heartburn, practical considerations for clinical practice as well as techniques available to study the ANC and buffering capacity of antacid formulations, and the benefits and drawbacks of methods used. This narrative will also assist pharmacists and other healthcare professionals in helping individuals with heartburn make informed self-care decisions as well as educating them to ensure that antacids are used in an optimal, safe, and effective manner, particularly in the era of the COVID-19 pandemic, in which reliance on self-care has increased.
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Materials and methods
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The databases Medline, Embase, and Google Scholar were searched for relevant studies using combinations of the following basic and Medical Subject Headings terms: “antacid,” “sodium bicarbonate,” “calcium carbonate,’ “magnesium carbonate,” “magnesium hydroxide,” “aluminum hydroxide,” “acid-neutralizing capacity,” “heartburn,” “gastroesophageal reflux disease,” “GERD,” and “gastric acidity.”
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Epidemiology of GERD
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In 2020, a meta-analysis of 96 studies from 37 countries reported the global pooled prevalence of GERD as 13.98%, with significant differences identified between regions and countries. In Asia, the estimated rate was 12.92%, versus 19.55% in North America and 14.12% in Europe. 9 Similarly, a previous study also estimated lower prevalence rates of GERD in Asia than in Western countries (10% vs. 14.1%–21.3%). 10 On the contrary, the actual prevalence of GERD in Asia is much higher and similar to that reported in Western countries, but is difficult to determine because of the lack of an exact word for heartburn in some Asian languages, the potential for patient self-treatment, and variation in diagnostic practices and definitions for heartburn and GERD. 11 For instance, the experience, understanding, and reporting of heartburn varied significantly among racial groups. The prevalence of heartburn was higher among African Americans (46.1%) and Caucasians (34.6%) but exceedingly low among East Asians (2.6%). 12 In addition, a group of experts who participated in a Delphi-based study on the management of GERD in the Asia–Pacific region reached a consensus that the prevalence rates of GERD in Asia are increasing. 13
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From 2006 to 2016, there has been a significant increase in the proportion of younger patients with GERD, especially within the age range of 30 to 39 years (15–19, 0.2%; 20–29, 2.4%; 30–39, 3.2%; 40–49, 2.8%; 50–59, 2.5%; 60–69, 0.8%, all P < 0.001). 14 Rising obesity and unhealthy dietary patterns might be some of the reasons behind this increased prevalence of GERD in the younger population. 15
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It has been estimated that at least weekly symptoms of GERD are most commonly observed among residents of North America (19.8%), followed by residents of Europe (15.2%), the Middle East (14.4%), and East Asia (5.2%). 16 In Australia, approximately 11.3% of the population has chronic GERD. 17 Some studies indicated that GERD symptoms are more prevalent in men than in women; however, evidence is conflicting, and the predominance in men cannot be reliably determined using current data. Nevertheless, complications from GERD do appear to be more prevalent in men. 16
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Impact of COVID-19 lockdown periods on gastrointestinal symptoms
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Lockdowns have brought significant lifestyle changes. Sedentary lifestyles, remote working, boredom, and anxiety evoked by COVID-19 lockdowns have a direct effect on individuals’ eating behaviors. Significant (P < 0.001) increases in meals consumed, binge eating, snacking, and unhealthy food consumption have been observed during COVID-19-related home confinement. 18 An Italian Internet-based survey among medical students analyzing gastrointestinal symptoms before and during the COVID-19 lockdown period reported an increased prevalence of heartburn (P < 0.001) and indigestion symptoms (P < 0.001) during the lockdown period because of changed dietary habits and anxiety symptoms. 19 Similarly, a cross-sectional survey comparing the prevalence of gastrointestinal symptoms in the Bulgarian adult population before and during the COVID-19 lockdown period reported increased rates of overall gastrointestinal symptoms (68.9% vs. 56.0%, P < 0.001), functional dyspepsia (18.3% vs. 12.7%, P < 0.001), and heartburn (31.7% vs. 26.2%, P = 0.002). 20
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Frequently used terms for heartburn
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Heartburn is a commonly used but frequently misunderstood word. There is no direct translation for the word heartburn in most languages. It is likely that some meaning may be lost in translation such that the word-for-word translation may carry a completely different meaning. The lack of an exact word for heartburn might contribute to low symptom reporting and a consequently low rate of diagnosis.21,22
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Heartburn is often associated with a sour taste in the back of the mouth with or without regurgitation of the refluxate. Heartburn has many synonyms, including “acid indigestion,” “acid regurgitation,” “sour stomach,” “hyperacidity,” and simply “acidity.” Heartburn is usually described as burning discomfort experienced behind the breastbone. Patients describe heartburn as a “burning sensation in esophagus, stomach, throat, trachea,” “a burning feeling rising from the stomach or lower chest up towards the neck,” “a burning, warm or acid sensation in the epigastrium, substernal area, or both,” “a burning feeling in epigastrium rises through the chest in substernal area,” or simply “a feeling of fullness or discomfort in epigastrium”.22 –26 In 2018, Clarrett and Hachem defined heartburn as a burning sensation in the chest that radiates toward the mouth because of acid reflux into the esophagus. 27 The terms “burning,” “hot,” and “acidic” are typically used by patients unless the symptoms become so intense that pain is experienced. 28
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Antacids as a mainstay intervention for reflux symptoms
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Acid suppression is the backbone for treating heartburn and other reflux symptoms. The World Gastroenterology Organization developed guidelines for the community-based management of common gastrointestinal symptoms recommending antacids, alginates, and histamine H2 receptor antagonists (H2RAs) as appropriate OTC treatment options for infrequent, mild, or moderate symptoms of heartburn. 29 Antacids provide rapid, but temporary and short-term relief of heartburn. Currently, antacid therapy is recommended for mild gastroesophageal reflux symptoms, whereas proton pump inhibitors (PPIs) is recommended for severe symptoms. 30 A position statement from the Indian Society of Gastroenterology on GERD management in adults also recommended PPIs in patients with frequent or severe symptoms. 31 Clinical studies demonstrated that antacid formulations containing sodium bicarbonate, calcium carbonate, aluminum hydroxide, or magnesium hydroxide/carbonate provide significant symptomatic relief against heartburn (Table 1).
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Table 1.
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Design, intervention (antacid salts), and findings of studies conducted among patients with gastroesophageal reflux disease-related conditions.
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Authors Study design Intervention (s) Treatment protocol Results
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Johnson and Suralik, 2009 51 Randomized, open-label, crossover study One dose (powder form) of a sodium bicarbonate (2.32 g) and citric acid (2.18 g) combination dissolved in water versus water alone – Interventions were provided at visit 2 or alternatively at visit 3 before breakfast– Doses was separated by a washout period of 36 to 48 hours – Treatment with a sodium bicarbonate and citric acid combination resulted in a statistically significant change in pH from baseline in 6 seconds, compared with 18 seconds for water.
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Walker et al., 2015 77 Phase III, randomized study Immediate-release omeprazole plus sodium bicarbonate (one dose [20 mg] per day) versus standard enteric coated omeprazole (one dose [20 mg] per day) – When required, interventions were provided for a period of 3 days during the 14-day study period – Immediate-release omeprazole plus sodium bicarbonate provided significant relief of heartburn associated with GERD within 0 to 30 minutes.
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Orbelo et al., 2015 78 Open-label, prospective, randomized clinical trial One sachet in 15 to 30 mL of water per day of an omeprazole and sodium bicarbonate combination – The intervention was provided daily for eight weeks either • in the morning, i.e., 20 to 60 minutes prior to a meal or • at night, i.e., immediately prior to sleep – The once-daily dose, taken in the morning or at night, effectively reversed severe reflux esophagitis and improved GERD symptoms.
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Higuera-de-la-Tijera, 2018 79 Systematic review of studies published since 2000 Omeprazole and sodium bicarbonate combination versus omeprazole NRa – The combination produced a sustained response and sustained total relief in patients with GERD.
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Sulz et al., 2007 80 Open, randomized, placebo-controlled trial Two tablets of a calcium carbonate (680 mg) and magnesium carbonate (80 mg) combination versus magaldrate gel (800 mg) versus placebo – Interventions were provided after an overnight fast of at least 10 hours on 3 different days– The scheduled days were separated by a washout period of 4 days – Both the antacid tablet and gel achieved the target pH (>3.0) during the first 30 minutes.
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Collings et al., 2002 81 Single-blind, four-treatment cross-over study Two pellets of calcium carbonate chewing gum (300 mg and 450 mg) versus two chewable tablets of calcium carbonate (500 mg) versus a swallowed placebo capsule – Interventions were provided 30 minutes after a meal in all four sessions – Both gums decreased heartburn for 120 minutes compared with placebo.– The higher gum dose decreased heartburn more strongly than chewable antacids up to 120 minutes.– Antacid gums provided faster and more prolonged symptom relief and pH control than chewable antacids.
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Rodriguez-Stanley et al., 2004 82 Prospective clinical study Two chewable tablets of calcium carbonate (1500 mg each) NAb – Calcium carbonate improved the motor function of the esophagus in patients with heartburn, thereby improving acid clearance from the esophagus and into the stomach.
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Robinson et al., 2001 83 Randomized, four-way crossover study Ranitidine (75 mg) versus a chewable calcium carbonate (420 mg), ranitidine, and calcium carbonate combination versus placebo – Interventions were provided 1 hour after a meal– Subjects underwent a 7- to 10-day washout period between each treatment – The combination was more effective in reducing meal-induced gastric and esophageal acidity as well as heartburn severity.
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Ohning et al., 2000 84 Open, randomized, placebo-controlled trial, four-treatment cross-over study Famotidine (10 mg), calcium carbonate (800 mg), and magnesium hydroxide (165 mg) combination versus ranitidine (75 mg), calcium carbonate (1000 mg) versus placebo – Subjects consumed a peptone meal both 60 and 15 minutes prior to treatment, and then 2.5 and 6 hours after treatment – The combination provided superior control of gastric acidity than either antacids or histamine-type-2 receptor antagonists alone.
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Walsh et al., 2000 85 Open (observer-blinded), randomized, placebo-controlled four-period crossover design Famotidine (10 mg), calcium carbonate (800 mg), and magnesium hydroxide (165 mg) combination versus ranitidine (75 mg) and calcium carbonate (1000 mg) combination versus placebo – Subjects consumed peptone meal both 60 and 15 minutes prior to treatment and then 2.5 and 6 hours after treatment – The combination reduced gastric acidity more quickly than ranitidine and continued to control gastric acidity for a longer period than calcium carbonate.
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Robinson et al., 2002 86 Randomized, crossover, placebo-controlled study Chewable (750, 1500, or 3000 mg) calcium carbonate tablets versus swallowable (750, 1500, or 3000 mg) calcium carbonate tablets versus placebo – Interventions were provided 60 minutes after dinner– The study period was separated by washout period of at least 24 hours – The onset of action on esophageal pH was similar for all antacids (30–35 minutes). – Chewable tablets and effervescent bicarbonate had relatively long durations of action (esophagus, 40–45 min; stomach, 100–180 min); conversely, swallowable tablets had little effect.
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Feldman, 1996 87 Randomized, double-blind, placebo-controlled crossover trial Two calcium carbonate antacid tablets (1000 mg) versus one famotidine tablet (10 mg) – Interventions were provided 60 minutes after the test meal– Two identical meals were consumed 2.5 and 6.0 hours after the medication was given – The onset of action of calcium carbonate was 30 minutes, versus 90 minutes for famotidine. – The duration of action of calcium carbonate was 60 minutes, versus 540 minutes for famotidine.
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||
Netzer et al., 1998 88 Double-blind, placebo-controlled, four-way crossover study Two tablets of a calcium carbonate (680 mg) and magnesium carbonate (80 mg) combination versus one tablet of ranitidine (75 mg) versus one tablet of famotidine (10 mg) versus placebo – Interventions were provided after an overnight fast – The onset of action, for raising pH to >3 was 5.8 minutes for calcium–magnesium carbonate, 64.9 minutes for ranitidine, 70.1 minutes for famotidine, and 240.0 minutes for placebo.– The percentage of time with pH >3.0 was 10.4% for calcium–magnesium carbonate, 61.4% for ranitidine, 56.6% for famotidine, and 1.4% for placebo.
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||
Levine et al., 2004 89 Randomized, double-blind, placebo-controlled, parallel group study Famotidine (10 mg), calcium carbonate (800 mg), and magnesium hydroxide (165 mg) combination (FACT) versus famotidine (10 mg; FAM) versus calcium carbonate (800 mg) and magnesium hydroxide (165 mg) combination versus placebo NAb – Onset of symptom relief was significantly faster with FACT than with FAM (P = 0.001) or placebo (P < 0.001).– Patients with heartburn who received FACT were 1.60- and 2.15-fold more likely to maintain adequate relief at a later time point than those on antacid and placebo, respectively.– The duration of the effect was significantly longer with FACT than with antacid or placebo (P < 0.001).– The proportion of episodes relieved for at least 7 hours was greater with FACT (70.0%) than with antacid (58.5%) or placebo (51.4%).
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||
Decktor et al., 1995 90 Single-blind, three-way crossover design Two chewable tablets of an aluminum hydroxide (800 mg), magnesium hydroxide (800 mg), and simethicone (80 mg) combination (AMH) versus calcium carbonate (1.5 g) – Interventions were provided 60 minutes after dinner – The onset of action was faster with AMH tablets than with calcium carbonate tablets.– The duration of the antacid action of AMH in the esophagus was 82 minutes, versus 60 minutes for calcium carbonate (P < 0.05).– In the stomach, AMH tablets raised gastric pH significantly compared with placebo (with a duration of action of 26 minutes), but the same was not observed for calcium carbonate.
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||
Parente et al., 1995 91 Double-blind randomized, multicenter study Aluminum phosphate gel (11 g) five times a day versus ranitidine (300 mg) once daily – Interventions were provided for 6 weeks – Ranitidine proved more effective than aluminum phosphate in reducing the frequency and severity of daytime pain attributable to duodenal ulcer.
|
||
Weberg and Berstad, 1989 92 Double-blind, randomized, placebo-controlled,crossover trial One chewable antacid tablet (containing 1100 mg of aluminum hydroxide and magnesium carbonate in a co-dried gel) versus a matching placebo – Interventions were provided four times daily– One tablet each was received 60 minutes after the three main meals and one was given at bedtime.– After 2 weeks of treatment, the patients were switched over to the alternative treatment for another 2 weeks– Treatment periods were not separated by any ‘washout interval’ – Antacid treatment provided significant lower global symptomatic scores, less acid regurgitation, and fewer days and nights with heartburn.
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||
Farup et al., 1990 93 Double-blind randomized, placebo-controlled,multicenter study One chewable antacid tablet (containing 1100 mg of aluminum hydroxide and magnesium carbonate in a co-dried gel) four times daily versus one cimetidine (400 mg) tablet twice daily versus a matching placebo – One antacid tablet each was received 60 min after the three main meals and one was given at bedtime for 8 weeks – Both antacids and cimetidine significantly reduced symptoms associated with reflux esophagitis compared with placebo. – During the first and second halves of the study, antacid consumption significantly improved the global assessment score versus cimetidine.
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||
Graham and Patterson, 1983 94 Double-blind, parallel-treatment study 15-mL doses of aluminum hydroxide and magnesium hydroxide combined liquid antacid versus an identical appearing placebo – Interventions were provided seven times daily, i.e., 1 and 3 hours after each meal (three in total) and at bedtime for five weeks – Both the antacid and placebo significantly reduced the severity and frequency of heartburn. – The time to reproduce heartburn was increased by both antacid and placebo therapy.
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||
Meteerattanapipat and Phupong, 2017 95 Randomized double-blind controlled trial 10 mL of alginate-based reflux suppressant (500 mg of sodium alginate, 267 mg of sodium bicarbonate, and 160 mg of calcium carbonate) versus 5 mL of magnesium-aluminum antacid gel (120 mg of magnesium hydroxide and 220 mg of aluminum hydroxide) – Interventions were provided three times after a meal and before bedtime for 2 weeks – No difference in the improvement of heartburn frequency, 50% reduction of the frequency of heartburn, improvement of heartburn intensity, and 50% reduction of heartburn intensity during pregnancy.
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aNot relevant because the article was a systematic review of different clinical studies.
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bThe data were not available in the published article.
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Antacids alone or in combination with PPIs/H2RAs have displayed superiority over placebo/active comparator in various randomized control trials of the treatment of hyperacidity/acid indigestion or GERD-related heartburn and upset stomach (Table 1). However, a discussion on PPIs and H2RAs will not be within the scope of this review article. In addition, a 2009 US community-based survey found that of 42.1% of patients with GERD symptoms who supplemented their PPI treatment with other GERD-related medications, 95.1% used OTC medications. 32 Among OTC medicine users, antacids were the most commonly chosen treatments (84.7% of patients). Antacids are generally considered to have a good safety profile, but high doses and chronic consumption can cause acid rebound through either gastrin release or the direct effect of antacids on parietal cells. 33
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Criteria for calling any product an ‘antacid’
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Antacids are compared quantitatively in terms of ANC, defined as the number of milliequivalents (mEq) of HCl required to maintain 1 mL of an antacid suspension at pH 3 for 2 h in vitro. According to the FDA, the active antacid ingredient(s) must contribute 25% of the total ANC of the product, and the finished product must contain at least 5 mEq of ANC as measured by the procedure provided in the United States Pharmacopeia 23/National Formulary 18. 34
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Impact of heartburn on quality of life and the relevance of antacids in self-care
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According to the Genval workshop report, a negative impact on health-related well-being is a criterion for reflux disease when heartburn occurs 2 or more days a week. 35 Studies revealed a significant decrease in well-being with increases in the symptom frequency of heartburn.36 –38 Patients with heartburn had work-related interferences, eating or drinking problems, sleep interruption, and severely impaired daily activity. 39 Nocturnal heartburn, found in 54 ± 22% of patients with GERD, can lead to poor sleep quality followed by sleep arousal, daytime fatigue, and impaired work productivity. 40 Treatment of heartburn symptoms has been significantly associated with improvement in quality of life.41,42 Based on this finding, the World Gastroenterology Organization suggests that the primary goals for self-treating frequent heartburn are the complete symptomatic relief and restoration of quality of life. 29 The reduction of heartburn symptoms is significantly associated with improved quality of life, with the greatest impact on psychological well-being and physical functioning. 41 The use of antacids alone or in combination with other therapies has produced improvements in vitality, physical and social function, and emotional well-being in patients with heartburn.43 –45 Thus, appropriate antacid use can improve health-related quality of life by ameliorating gastroesophageal reflux symptoms.
|
||
|
||
The World Health Organization defines self-care as “the ability of individuals, families and communities to promote health, prevent disease, maintain health, and to cope with illness and disability with or without the support of a healthcare provider,” which includes non-drug self-treatment and self-medication.46,47 Amid the COVID-19 pandemic, self-care and self-management are even more critical aspects of the evolving healthcare system to manage self-recognized minor ailments such as heartburn and acid regurgitation. The demand for antacids and various OTC medicines has increased because these treatments have proven appropriate for addressing the unmet needs of consumers. 48
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|
||
This adds to the importance of optimal interfacing between health systems and sites of healthcare delivery. Pharmacists play a vital role in assisting patients to choose self-care approaches and select optimal OTC medicines. Pharmacists can advise consumers on the safe and effective use of antacids, reinforce directions provided by the product labeling, help cease inappropriate use of antacids, and address their interactions with other medications.
|
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|
||
Practical considerations in the use of antacids
|
||
|
||
The following factors must be considered by healthcare professionals when prescribing/suggesting an antacid:
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|
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Pros and cons of various antacids ingredients
|
||
Supporting body of evidence
|
||
Impact in special populations
|
||
Comorbidities and concomitant medications
|
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ANC
|
||
Buffering capacity
|
||
Risk of rebound acidity
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Antacid ingredients: mechanisms to clinical evidence
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Antacid products come in powder, tablets, or liquids dosage forms. Antacids contain salts of magnesium, aluminum, calcium, sodium, carbon, or bismuth in their formulations. The combination of two salts, such as magnesium and aluminum, form the principal composition of most antacids. 49 With normally prescribed doses, antacids raise gastric pH significantly; however, the onset of action depends on the dose, dosage forms, and extent of chewing (for tablets). For example, powder forms of antacids exhibit a faster onset of action than liquid forms. 50 Effervescent powder forms of sodium bicarbonate antacids can start neutralizing acid in a few seconds. 51 Antacids have a duration of action of 20 to 60 minutes when ingested on an empty stomach. After a meal, approximately 45 mEq/hour HCl is secreted. A single dose of 156 mEq of antacid given 1 hour after a meal neutralizes the acid for up to 2 hours. 52 The ANC of different formulations of antacids is highly variable. Powder and liquid preparations of antacids usually have higher ANCs than tablets. 53
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Antacids have been classified into two classes: systemic or absorbable and non-systemic or non-absorbable antacids. Absorbable antacids are readily absorbed into the systemic circulation, and they can produce systemic electrolytic alterations as well as alkalosis (e.g., sodium bicarbonate). Non-absorbable antacids such as aluminum hydroxide, aluminum phosphate, calcium carbonate, and magnesium hydroxide are not absorbed to a significant extent; e.g., only 15% to 30% of calcium and 5% to 10% of magnesium are absorbed from their respective antacid formulations.54 –56
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||
Each antacid ingredient has a unique mechanism with the ultimate goal of acid neutralization (Figure 1). Ingredients with different features and limitations provide options to physicians for addressing the intra- and intersubject variability of patients. The features and limitations of various antacid ingredients are presented in Table 2.
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An external file that holds a picture, illustration, etc. Object name is 10.1177_03000605221086457-fig1.jpg
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Figure 1.
|
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|
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Effects of different antacid ingredients on gastric acid. The representative figure presents the mechanism of carbonate salts only. Other antacid salts were discussed in the article. Most of the gastric acid (approximately 45 mEq/h) is secreted across the apical membrane of the stomach through a proton pump (H+/K+ ATPase) after meal consumption. The carbonate salt of antacids binds to H+ ions from gastric hydrochloric acid to produce chloride salts (calcium chloride, sodium chloride, magnesium chloride, and aluminum chloride), carbon dioxide, and water. This decreases H+ concentrations in the stomach, thus raising the pH. The orange region denotes the acidic environment of the stomach, the green region denotes the antacid-mediated neutralization/adsorption of gastric acid, and the yellow region denotes alkalized/neutralized gastric acid. In the alkaline conditions of the small intestine, soluble calcium chloride, sodium chloride, magnesium chloride, and aluminum chloride are converted back to their carbonate salts. The sodium bicarbonate rapidly empties into the small intestine, where it is absorbed; thus, it is considered an absorbable antacid. Calcium carbonate, magnesium carbonate, and aluminum carbonate are excreted with the stool, decreasing their absorption; thus, they are considered non-absorbable antacids.
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Table 2.
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Features and limitations of different types of antacid salts.
|
||
Saltsa
|
||
Calcium Sodium Magnesium Aluminum
|
||
Speciesb Carbonate Bicarbonate, citrate Hydroxide, carbonate, oxide, trisilicate Hydroxide, carbonate, phosphate, glycinate
|
||
Category Non-absorbable Absorbable Non-absorbable Non-absorbable
|
||
ANC (mEq/15 mL)c 58 17 35 29
|
||
Maximum daily dosage limit (mEq)d 160 200 (≤60 years old) and 100 (>60 years or older) 50 NA
|
||
Limitations • Constipation and flatulence• Systemic alkalosis and hypercalcemia on long term use• Occasional milk-alkali syndrome in patients taking more than the recommended dose • Non-serious, stomach/gut irritations that could cause gas or bloating • Dose-related diarrhea• Flushing• Hypotension• Vasodilation• Hypermagnesemia • Hypomagnesemia• Hypophosphatemia• Constipation• Anemia
|
||
FDA category for antacid use in pregnancye None None None None
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||
Contraindications
|
||
Renal impairment No Yes Yes Yes
|
||
Hepatic impairment No Yes No No
|
||
Allergy to the antacid ingredient(s) in the formulation Yes Yes Yes Yes
|
||
Others • Patients with hypercalcemia, hypercalciuria, nephrocalcinosis, and nephrolithiasis• Patients on a low-phosphate diet • Patients on a sodium- restricted diet, e.g., those with hypertension or congestive heart failure • Patients with severe diarrhea • Patients with neuromuscular disease such as myasthenia gravis • Patients with constipation
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aA salt is a chemical compound consisting of an ionic assembly of positively charged cations and negatively charged anions. The specific salts of active pharmaceutical ingredients are often formed to achieve desirable formulation properties. 96
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bChemical species are specific forms of a particular element, such as an atom, molecule, ion, or radical. For example, chloride is an ionic species. 97
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cThe potency of an antacid is generally expressed in terms of its ANC, which is defined as the number of mEq of 1 N HCl that are brought to pH 3.5 in 15 minutes (or 60 minutes in some tests) by a unit dose of the antacid preparation. 98
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dAs per the federal register of the US FDA 99
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eAntacids carry a FDA pregnancy category of None (N), meaning these drugs have not been classified by the FDA. 65
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mEq, milliequivalents; ANC, acid-neutralizing capacity.
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Calcium carbonate: Calcium carbonate reacts with gastric HCl to produce calcium chloride, carbon dioxide, and water. Calcium ions decrease heartburn symptoms by stimulating peristalsis in the esophagus and moving the acid into the stomach. Carbonate anions bind to free protons (H+) from HCl, hence decreasing H+ concentrations in the stomach and raising pH. In the alkaline conditions of the small intestine, soluble calcium chloride is converted back to calcium carbonate followed by excretion in stool, decreasing its absorption. 55
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Sodium bicarbonate: Sodium bicarbonate, a rapidly acting antacid, reacts rapidly with gastric HCl in the stomach to produce sodium chloride, carbon dioxide, and water. Excess bicarbonate rapidly empties into the small intestine, where it is then absorbed. Sodium bicarbonate is often combined with citric acid. This combination reacts immediately with water to produce sodium citrate solution with the concomitant liberation of carbon dioxide. Sodium citrate is a fast-acting acid neutralizer that in suitable doses can raise stomach pH.
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Magnesium salts: Magnesium hydroxide reacts rapidly with gastric HCl to produce magnesium chloride and water. Magnesium carbonate reacts with gastric HCl to produce magnesium chloride, carbon dioxide, and water. Magnesium trisilicate dissolves slowly, and reacts with gastric HCl to produce magnesium chloride, silicon dioxide, and water.
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Aluminum salts: Aluminum hydroxide reacts with gastric HCl to produce aluminum chloride and water. Aluminum carbonate reacts with gastric HCl to produce aluminum chloride, carbon dioxide, and water. Aluminum phosphate reacts with gastric HCl to produce aluminum chloride and phosphoric acid.
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Pepsin and bile acid inhibition activity
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Pepsin is a proteinase that is produced from the inactive form pepsinogen by the parietal cells of the gastric mucosa, whereas bile acid is a digestive liquid produced by the liver.
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||
Pepsin is activated at pH 1 to 2, and it has limited activity when the pH is around 3.5 to 5. 57 Glyco- and tauro-conjugated bile acids have been reported to be harmful to the esophageal mucosa at acidic pH (pH <4 and even down to pH 2 for tauro-conjugated bile acids). 58 In patients with reflux disease, both pepsin and bile acids have been found in the esophageal reflux. 59 Pepsin in the refluxate disrupts the esophageal mucosal barrier by acting on the epithelial cell surface, whereas bile acids achieve the same effect by diffusing into cells and damaging them. 60 Thus, the activity of pepsin and bile acids should be limited to prevent such damage. In 1971, an in vitro experiment by Kuruvilla revealed high anti-peptic activity (82% and 81%, respectively) for both magnesium carbonate and calcium carbonate. 61 In addition, aluminum and calcium antacids appear to adsorb pepsin and reduce its activity more strongly than would be predicted by pH changes alone. 62 Antacids such as magnesium and aluminum hydroxide can bind to bile salts, but magnesium hydroxide binds to bile salts at a much lesser extent than aluminum hydroxide.52,63 Thus, antacids are used as add-on treatments for gastritis, peptic ulcer disease, and esophagitis.
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Special populations
|
||
Management of heartburn during pregnancy
|
||
|
||
Heartburn is a common consequence of pregnancy. Prior research presented the prevalence of heartburn as 22% in the first trimester, 39% in the second trimester, and 60% to 72% in the third trimester. 64 Increases in the levels of female sex hormones such as progesterone can reduce lower esophageal sphincter pressure. The step-up algorithm, starting with dietary changes and lifestyle modifications, should be used to manage heartburn during pregnancy. Antacids carry an FDA pregnancy category of none (N), which means these drugs have not been classified by the FDA. 65 Antacids are recommended as first-line treatments for heartburn in pregnancy when lifestyle modifications fail. If symptoms persist despite antacid use, then H2RAs can be used, excluding nizatidine because it has been found to be teratogenic in animal studies. All PPIs and H2RAs are FDA category B drugs, excluding omeprazole, which is an FDA category C drug. PPIs are reserved for women with complicated GERD or intractable symptoms. Approximately 30% to 50% of pregnant patients with symptoms will never need to “step-up” therapy from antacids. Although magnesium-, calcium-, and aluminum-containing antacids display good safety profiles during pregnancy, they should not be used for long-term therapy or in large doses.66,67 Treatments containing sodium bicarbonate should be avoided in pregnancy because of risks of fluid overload as well as maternal and fetal metabolic alkalosis risks (Table 2).
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Management of gastroesophageal reflux in children
|
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Infants normally experience gastroesophageal reflux symptoms that peak at 4 months of age because of physiological factors, and these events resolve over time. Antacids are not useful in infants with reflux symptoms, but they may be considered for short-term use in older children (12 years and older) to relieve heartburn.68,69 If regurgitation becomes frequent, then lifestyle changes, postural therapy, and thickened feedings should be considered.70,71
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Comorbidities and concomitant medications
|
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Similarly as any other medicines, antacids can potentially cause drug–drug interactions, especially in patients with comorbidities such as renal or hepatic impairment in those taking concurrent medications without medical supervision. Antacids can influence the rate and/or extent of absorption of concurrently administered drugs with pH-sensitive release from a dosage form, pH-dependent stability, or pH-dependent solubility by increasing gastric pH. 72
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ANC and reliability of the in vitro test used
|
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||
ANC, stated in mEq, is the amount of acid that can be neutralized using one standard dose of an antacid. The most effective antacids should have a high ANC that can be estimated by back titration through in vitro experiments. 73 The back titration method, a static test, is useful for comparing the level of neutralization achievable by a range of antacids, but it does not consider their rate of reaction. At least three variables, namely gastric secretion, gastric emptying, and the acid-consuming capacity, influence the efficacy of an antacid in vivo. The impact of the former two variables cannot be determined by back titration. However, more sophisticated in vitro models (e.g., dynamic simulators) can both measure all of these variables and offer a faster and more ethical alternative to studies in animals and humans. 74 According to the Committee for Medicinal Products for Human Use, the therapeutic equivalence of locally acting gastrointestinal products can be demonstrated using these in vitro or in vivo methods, provided they have been proven to accurately reflect in vivo drug release and availability at the sites of action. 75 The type of studies required to demonstrate equivalence should be determined via careful consideration of the product characteristics, mechanism of action, underlying disease being treated, validity of any in vitro or in vivo studies, the effects of any excipients, and differences in dose delivery systems.
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|
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Buffering capacity and reliability of the in vitro test used
|
||
|
||
Various in vitro tests have been developed to evaluate the buffering capacity of antacids. These tests include pH-stat titration and continuous acid challenge tests such as the Rossett–Rice method, the Simulator of the Human Intestinal Microbial Ecosystem (SHIME®), and the TNO Simulated Gastro-intestinal Tract Model 1 (TIM-1). These tests are dynamic, and they provide a more precise measure of antacid reactivity. pH-stat titration provides an accurate estimation of the rate at which the antacid is reacting under in vitro or fixed conditions, but it provides little information of its in vivo behavior.
|
||
|
||
By contrast, continuous acid challenge tests can serve as predictors of in vivo behavior. These tests are generally used to measure maximum pH achieved by an antacid, its duration of action, and the amount of antacid that will be lost if gastric emptying is simulated. The gastric emptying rate is an important factor for slowly reacting antacids such as magnesium trisilicate. The Rossett–Rice test is an acid neutralizing dynamic assay used as a standard to evaluate or compare the in vitro efficacy of antacid formulations. Using the Rossett–Rice test, Deepika et al. reported that the pH of acidic content was increased to 3.5 significantly faster and pH ≥3.5 was retained for a longer period with a sodium bicarbonate, sodium carbonate, and citric acid combination than with an aluminum hydroxide, magnesium hydrochloride, and simethicone combination. 50 The SHIME® apparatus mimics the physiological and microbiological conditions of the human gastrointestinal tract. The apparatus is the conglomeration of five reactors simulating different processes that occur in the human gastrointestinal tract. The steps required for food uptake and digestion in the stomach and small intestine are simulated by the first two reactors, whereas the other three compartments represent the ascending, transverse, and descending colon, respectively. 76 TIM-1 is a computer-controlled, dynamic, multi-compartmental system that simulates all physiological processes of the human upper gastrointestinal tract (lumen of the stomach and small intestine). 74 It offers relatively easy manipulation, reproducibility (no biological variation) and, most importantly, accuracy compared with in vivo techniques.
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|
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Summary
|
||
|
||
Antacids are widely used globally for the treatment of symptoms of acid-reflux related conditions. Despite their rapid action and good safety profile, antacids with a high ANC and good buffering capacity are required for the efficient management of these conditions. The ANC and buffering capacity can be measured using well-established test methods, thus making them predictive of the clinical effectiveness of antacid preparations in relieving gastrointestinal symptoms. For these reasons, providing the ANC and buffering capacity on labels as previously suggested could help ensure the quality, efficacy, and value of antacids. Nevertheless, the potential for adverse effects or drug interactions exists. Awareness of these possibilities is important because patients often fail to inform their physicians about antacid use unless specifically asked. Self-care and self-management are critical aspects of the evolving healthcare system in managing self-recognized minor ailments such as heartburn and acid regurgitation. To support this, pharmacists, the most accessible healthcare professionals, can improve patients’ awareness about antacid therapy and its related possibilities through counseling and education.
|
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|
||
Acknowledgements
|
||
|
||
Syed Obaidur Rahman, Rajiv Kumar, and Nitu Bansal from WNS Global Services provided editorial and medical writing assistance with funding from GSK Consumer Healthcare.
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|
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As a Linux fanboy, I must confess Linux is actually sucks for "normal people"
|
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|
||
Let break down what do the "normal people" need, shall we:
|
||
|
||
They need something easy to use, software, occasional gaming, meetings and for things to work
|
||
|
||
But desktop Linux doesn't provide that oh no!
|
||
|
||
Modern hardware will always have issues, loss of functionality and so on. Even models from 2018 still lack drivers. For example, AMD still has ass power management which 6.3 will *hopefully solve that.
|
||
|
||
Enjoy your 4k screen with no scaling *yet (pls, qt6)
|
||
|
||
Hardware decoding still sucks on most browsers, some distro enable by default, most don't. Use chromium? might as well kill yourself first. Spyware MS Edge is ironically the best chromium based browser on Linux??
|
||
|
||
MS Teams is dropping support for Linux so you can have more fun with corporate conferences. Forgot the mention, want to share your screen? wait nvm let me quickly log out while I am representing, wasting people time because I choose Linux.
|
||
|
||
No hi-fi music on Linux also, so say good bye to your Tidal subscription.
|
||
|
||
Some apps, like Brave, adapt to the 9px font on Windows and Mac, so it has bad UI in Linux and smaller tab UI than usual. Some people even said most fonts are not rendered correctly under Linux, don't know if that is true but yeah.
|
||
|
||
Want to buy hardware? more time wasted and it is even more of a pain in the ass using Linux with laptops that doesn't have Linux support. Like in the case of Lenovo Yoga something, the sub woofer is non functional resulting in poor speakers in under Linux. Also, most people will just say laptop works perfectly but I can guarantee at least something is missing.
|
||
|
||
Speaking of speakers, on the laptop, windows uses some kind of tuning, EQ but Linux let you do it yourself so more time wasted to get to speakers sound as good.
|
||
|
||
What about your favorite apps on Linux....wait what the developers can just ditch their work anytime? cool
|
||
|
||
So you have a PDF that needs to be edited? good luck wasting time finding the right software. Who would have thought the PDF viewer can only view PDF and you need another app to edit them. But you can use Libreoffice draw tho, no cool! until draw breaks the layout. Or maybe you need to crop an image, more time wasted then.
|
||
|
||
Want to seek help, oh look condescending Linux assholes in the wild, fanboys that will downvote you
|
||
|
||
At the end of the day, people who use Linux as their daily driver or on a relatively modern hardware....just feel like they are handicapping themselves, always wasting time to get things work, time that can be spent on others. Your laptop battery sucks, your browser doesn't have hardware decoding, your meetings are unstable, you can't share your screen. Apps you use don't work that well. You can't enjoy your screen because of small scaling and blurry fonts. I am not even mentioning the time wasted finding alternatives for windows apps.
|
||
|
||
There is a price to everything, with windows you pay it with your data and money lol, with Linux you pay with your time. Like the right of privacy, you pay for it with your time and most people don't have that. People may hate ads, tracking, privacy violations but what they hate more is basic things just do not work. Actually, we don't hate windows, windows 7 was decent enough, we hate what Microsoft did to windows. If you work in IT, ignore these, unrelated. I used to be a Linux fanboy, it was the best, why don't people use it more. Now, everything is just grey.
|
||
|
||
This post might seem bias and seems like I hate Linux, but I will continue to handicap myself and waste more time for the right of controlling my hardware and software, the good privacy and security and the support for the good developers. Besides, Gnome workflow is too good, can't leave
|
||
|
||
I fucking love and hate you Linux
|
||
This is me and I disagree. My 6 years or so of using Linux as my daily driver after running Windows for 25 years is like escaping a prison. Such a fucking relief to not have to deal with MS's bullshit, bloat and instability. I'd never go back.
|
||
|
||
What about your favorite apps on Linux....wait what the developers can just ditch their work anytime? cool
|
||
|
||
How is this different on Windows or MacOS?
|
||
|
||
good luck wasting time finding the right software.
|
||
|
||
How is it different on Windows? If you don't know the name of the software you kinda have to search for something.
|
||
|
||
Who would have thought the PDF viewer can only view PDF and you need another app to edit them.
|
||
|
||
It is in the name.
|
||
|
||
|
||
for me, linux is a escape from prison. whenever I have to deal with windows, its always something stupid, wifi not working, cannot add printer, or cannot change printer settings, errror messages means shit ton of things and nothing at the same time, and honestly, 90% of problems on windows require reinstall. Ended the times where problems were solvable. You either upgrade, if you didnt yet, or roll back, if you did, or reinstall, if you cannot do either.
|
||
|
||
I will never go back to windows.
|
||
|
||
|
||
Honestly, never once have I felt handicapped using Linux; in fact, it's been the opposite. 🤷♂️
|
||
|
||
Different strokes for different folks, though.
|
||
|
||
|
||
First and foremost, skill issue. Second, you are just bad at maintaining your system. If you want stuff to work, then do research, nobody holds your hand, because Linux is not a commercial product.
|
||
|
||
The problem with Linux is not Linux itself, but the proprietary stuff, that is walled off by companies, which want you to keep using their shitty platforms and leech on you at every single opportinity.
|
||
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Also, nobody cares. If you can't bear "wasting time" on Linux, then don't use it. Most changes happen when people either contribute, or support developers of the software they enjoy. If you just use stuff without giving anything back, don't come ranting about everything being crap - that's entirely on you.
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Yeah, but Windows has so many of its own problems. One tends to forget these problems after using a Linux distro for several years. You're right that there aren't nearly as many convenient 3rd party apps, like PDF related apps, for Linux as for Windows; as well as third party viruses, adware and malware "applications" that continue to ignore Linux systems. How thoughtless.
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I have a friend for whom I installed Linux years ago. He had troubles with it—the usual Linux troubles. He was NOT savvy, so when he got a brand new laptop I said: 'Why not lets keep Windows on it and everything will "just work"?' Within a week, literally a week, he called me up to say that the system had been infected by viruses while he'd been "visiting the Ladies". He'd then gotten a call from a Microsoft Tech Support outfit in Calcutta, India. They kindly installed a remote desktop and proceeded to fix his Windows installation. I gently explained that he might want to bring his laptop to my place. STAT. He demanded that I install Linux; and it's been fine since then. Oh, except for installing his HP Printer. That was a PITA. First of all, HP techs got all pissy that he was using Linux and second that they couldn't sign him up for their buy-our-ink-or-we'll-remotely-shut-off-your-fucking-printer-until-you-fucking-pay-us-program. Respectfully. He was so determined to continue using Linux that he actually Googled how to install it himself. And did it. That was a huge Linux baby-step. So... I relate this story because you would expect somebody like him to use Windows and never turn back, but he despises Windows. Linux is a better OS for him.
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As for myself, I switched to Linux in the early to mid aughts because the MS knowledge base was a PITA and largely worthless. If some bored MS-Tech thought your bug was beneath them, then sucks to be you. In Linux, even with its own arrogant pricks, one at least has a far better chance of either fixing a bug or finding a workaround. It's doable in Linux because it's open source. In the meantime, everyone in my family uses Linux, including my college-aged kids. I insisted they install Windows *and* Linux on their systems because some college apps only run on Windows, but they still all prefer Linux because it's cleaner, faster and infinitely more customizable; and always default to Linux (I've asked because I'm curious). That said, one of my daughters is eventually going to go Apple and never turn back. She has a taste for the finer things in life. Anyway, my point is that a lot of end users who you'd expect to prefer Windows, actually much prefer Linux despite Linux's own limitations.
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respectfully, that is a skill issue.
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i’m convinced that you want to use linux like you want to use windows. doing it this way won’t work well, if it even works at all.
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you need to effectively re-learn how to use your pc. it’s as easy if not easier than windows to use linux, but you need to learn how to use it.
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There are a lot of entitled users of free software that complain that this or that doesn't work, whilst not actually contributing in any way.
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Linux isn't perfect but if it causes so many problems find another tool that works for you. That's all Linux is, a tool to perform tasks.
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I find all the complaints disagreeable, disrespectful and unappreciative in many cases. If you don't like it, don't use it. A lot of people go to a lot of effort, many sacrificing their own personal time, to give people the many tools that make up Linux.
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