STOMACH MUSCLE

NATALIE ADAMS

Customers looking to self-treat an upset stomach want an over-the-counter product that works . . . and works fast, pharmacists say.

Generally, pharmacists say double-strength and fast-acting liquids fill the bill. One notable exception concerns women customers, for whom many pharmacists recommend calcium-containing antacid tablets.

Pharmacists' recommendations may soon shift dramatically, however. Hovering over the entire OTC category of antacids is the possibility that low-dose strengths of a number of anti-ulcer agents could gain Food and Drug Administration approval soon. Pharmacists say approval of any of the currently pending FDA applications -- including not only low-dose cimetidine, but low-dose formulations of ranitidine and famotidine as well -- would turn the $845.2 million antacid category on its head.

"Most of the time I recommend a double-strength product," says Paul Montague, pharmacy manager at Hen House Pharmacy, Kansas City, Kan.

Montague says he bases his recommendation on efficacy. "I go by more of what works than flavor or taste. As it happens, the one I recommend the most, [Johnson & Johnson/Merck Consumer's] Mylanta Double Strength not only works, but is pretty good tasting, too.

"I tell people the liquids work quicker. That's what I use at home," adds Montague.

Jim Killingbeck, pharmacy manager at a Benton Harbor, Mich., Meijer Pharmacy, gives similar advice.

"I usually go straight to the double-strength, and I try to steer them to the liquids unless they have a strong objection. The liquids are faster acting because the ingredients are already dispersed."

"I base my recommendations on strength," says Ron Wellman, pharmacy manager at Supervalu's Clyde Evans Pharmacy, Lima, Ohio. "Most of the time I recommend a liquid -- usually Mylanta Double Strength -- because it works faster."

"People are sticking with the liquids," says Ron Bowie, pharmacist at Allen's of Hastings in Hastings, Neb. But he adds, "Of course, if they [SmithKline Beecham] ever get Tagamet over the counter, that'll really be a change."

A survey conducted earlier this year by Supermarket Pharmacy (May 28 issue) supports pharmacists' apparent preference for liquids over tablets. Pharmacists said they recommend a liquid or effervescent antacid an average of 8.5 times a week, compared with 6.4 times weekly for antacid tablets. Whether a product was previously available only on prescription ranked third after product quality and confidence in the manufacturer among factors influencing pharmacists' choices of gastrointestinal remedies.

Other pharmacists reserve recommendations of double-strength antacids for when something stronger seems to be needed.

"I'll recommend a double-strength to patients depending on how strong their complaints are," says Artie Gatewood, pharmacy manager at Buehlers Buy Low

Pharmacy, Evansville, Ind. "If they complain of very uncomfortable burning, I'll tell them to use a double-strength product," he explains.

"I only recommend it if a patient comes to me and says the [regular] product is not working," says Tony Gallo, pharmacy manager at a Peabody, Mass., Purity Pharmacy.

Gallo adds that he prefers liquid antacids. "Tablets get caught in the teeth. If the person's traveling, then you have to go with the tablets."

"It all depends upon convenience -- whether they want to walk around with a tablet instead of a bottle of liquid," says Gary Niezgodzki, pharmacy manager at an Abco pharmacy in Phoenix.

"Liquids seem to have a better consumer perception that they are stronger," says Brian Woo, business manager for Parke-Davis' Consumer Health Products Group, Morris Plains, N.J. He adds, however, that in terms of market growth, "there is a shift toward the tablets because of their convenience."

Sales of tablets, in fact, are edging out liquids. According to Towne-Oller & Associates, New York, tablets accounted for 55.1% of category sales in food stores, with sales of $226.9 million, compared with 35.5% for liquid antacids, with sales of $146 million, for the 12 months ended in October 1994.

While sales of liquids and chewable tablets dominate the category, antacids in a variety of dosages and flavors have been launched recently.

Procter & Gamble, Cincinnati, began test-marketing its Pepto Heartburn Control in the Phoenix-Tucson area Nov. 4. The liquid is available in regular and double-strength, with simethicone for gas relief. The tablets contain calcium carbonate. Both tablets and liquid come in cherry and mint flavors.

Johnson & Johnson/Merck recently launched lozenges and gelcaps as extensions of its Mylanta line.

Miles Inc., Elkhart, Ind., this fall relaunched its Alka Mints, a calcium carbonate-based tablet. Miles also markets Alka-Seltzer, which has experienced growth, according to Bruce Montgomery, product manager of Miles' gastrointestinal group for Miles.

Part of the popularity of chewable antacid tablets that are high in calcium is due to their potential dual use as a calcium supplement.

"When a woman comes in, it's always [SmithKline Beecham's] Tums with calcium," Gallo of Purity Pharmacy says. "I recommend the product because of the extra calcium to use as a calcium replenisher, and also because it works" as an antacid.

"I've been recommending the antacids with more calcium mainly to women as a type of calcium supplement, as well as for an antacid," adds Niezgodzki of Abco.

For patients who suffer from gas as well, pharmacists are recommending dual-purpose antacid-antigas products.

"Some patients have been asking for antacids with an antiflatulent ingredient," says Killingbeck of Meijer Pharmacy. "We find out in counseling the patient that gas is a problem, in addition to the burning."

"It's usually upon my asking that I find out if the patient needs an antiflatulent," says Gallo. "If it's strictly a gas problem, I usually go with [Sandoz Consumer's] Gas-X, but for an antacid with gas relief, I like [SmithKline Beecham's] Gaviscon."

"I've been recommending antacids with antiflatulent ingredients if there is a gas problem," says Niezgodzki. "I'll tell them to get something with simethicone."

Price is another factor that affects patients' choice of antacids, and pharmacists' recommendations as well. About 5.4% of antacids purchased in supermarkets are private label or store brand, up one percentage point from 1993, according to the Private Label Manufacturers Association, New York.

Gallo of Purity Pharmacy says he makes his recommendations of antacids based on pharmacology, therapeutics and what he feels is best, regardless of cost, but he adds sometimes people will counter his brand recommendation with the price factor.

"If they ask if you have your own brand, then you know price is an issue for them," says Gallo, who will then recommend a store brand.

Pharmacists' recommendations as well as antacid sales would likely undergo a seismic shift if any of the applications for low-dose formulations of anti-ulcer agents to treat heartburn are approved by FDA.

Niezgodzki says he has already had people ask him about Tagamet for OTC use. "They want to know when it's coming out, and is it available OTC yet.

"My recommendations [for OTC cimetidine] would depend on the type of patient. If I thought the patient had a hiatal hernia or a possible ulcer, I'd recommend it," says Niezgodzki.

Last July two panels of advisers to FDA recommended against approval of SmithKline Beecham's aplication for OTC availability of 200-milligram cimetidine because of concerns that it may interact with patients' other drugs. FDA has yet to rule on applications for OTC dosage strengths of ranitidine (Zantac) by Glaxo, Research Triangle Park, N.C., and famotidine (Pepcid), by Merck, Rahway, N.J.

Many pharmacists indicate they would be cautious about recommending OTC versions of anti-ulcer drugs, particularly cimetidine, for their patients. They say intensive counseling of patients should be part of such switches, preferably by having these products placed in a "pharmacist only" or third class of drugs that would be sold only in pharmacies.

"I'd like to first ask them questions concerning the origin of their stomach problem to determine whether it's heartburn or the beginnings of a heart attack" before recommending a product such as OTC cimetidine, says Jim Hill, pharmacist at Country Counter Stop-N-Shop, West Richfield, Ohio.

Pharmacist Julie Baillie of Food Circus Pharmacy, Wall, N.J., agrees. "Patients should either come to the pharmacy with a prescription, or even if they asked for it [cimetidine], pharmacists should at least be able to ask a few questions to see if the person is not having an active gastrointestinal bleed," she says.

Such patients "may need to be medically followed up if they have anemia or some type of bleeding," says Baillie. "I would prefer to speak to them and tell them that they should have regular checkups from their doctor," she adds.

Pharmacist Phil Thomas of Cee Bee's Finer Foods, Carol Stream, Ill., says if a drug such as cimetidine were to go over the counter, "I'll have no choice but to recommend it. I believe it should go into a third class of drug so the pharmacist maintains some type of control over who gets it," he says.

"I think pharmacists should play a major role in controlling who gets drugs that are switched from Rx to OTC," Bowie says. "I'm a proponent that there should be a third class of drug available to the public upon recommendation from the pharmacist. Before I made a recommendation of an OTC switch, I would want to get a good history of the patient's symptoms," he says.

"As a pharmacist, I think it's used too much now, when the doctors are having to prescribe it," says Bowie, of cimetidine. "I think if it went over the counter, it would be that much more abused."

Hill of Country Corner says OTC availability of the anti-ulcer drugs could also lead to people treating symptoms of an ulcer rather than get treated with an antibiotic regimen that could eradicate the problem.