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PDAT2 > 26 - GERD > Flashcards

26 - GERD Flashcards

1
Q

Pathophysiology of GERD

A

Motor Abnormalities

  • *Defective LES**
  • *TLESRs** = Transient LES relaxations
  • Impaired* esophageal acid clearance
  • delayed* gastric emptying

Hiatal Hernia = antomical issue with diaphrapgm

Visceral Hypersensitivity

impaired mucosal resistance / defence mechanisms

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2
Q

Medical / Surgical Factors

that may Precipitate GERD

A

Pregnancy

Asthma

Scleroderma (hardening of tissues)

Gastroparesis = slow motility of gut

Zollinger - Ellison Syndrome

Nasal Tube Intubation

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3
Q

MEDICATIONS

that cause a DECREASED LES Pressure

A

Anti-Cholinergics / Serotonin Antagonist

Barbiturates / GABA Agonist

Caffeine / coffee / Alcohol

Dopamine / Estrogen / Progestrone

Morphine / Ethanol / Nicotine

Tetracycline / theophylline / Nitrates

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4
Q

MEDICATIONS

that are DIRECT Mucosal irritants

GERD

A

Alendronate

ASA / NSAIDs

IRON

Quinidine / Potassium-Chloride

spicy foods / citrus / tomato / COFFEE

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5
Q

Esophageal Symptoms of GERD

A

HEARTBURN
pyrosis

Regurgitation
reflux

  • *Dysphagia
  • difficulty swallowing***

Nausea

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6
Q

EXTRA-Esophageal

Symptoms of GERD

A

caused by GERD –> affects other areas

CHEST Pain

Cough

Asthma Worsening

Laryngitis

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7
Q

Typical / A-Typical

Symptoms of GERD

A

TYPICAL
Heartburn / HyperSALVation / Belching / Regurgitation

A-Typical
Hoarseness / Dental Erosions
Non-allergic Asthma / Chronic COguh
Pharyngitis / Chest Pain

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8
Q

Patient Characteristics or Complications
ALARM SYMPTOMS
When to Refer to MD for GERD

A

Pregnant / Elderly / Infants

History of:
GI Disorders / IBD / PUD

Complications:
Barrett’s Esophagitis
Esophageal Cancer
if alarm symptoms –> refer for ENDOSCOPY

BLOOD IN GENERAL

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9
Q

ALARM SYMPTOMS

​When to Refer to MD for GERD

A

Anemia / GI Bleeding / Vomitting
= BLOOD IS BAD

Chest pain = Heart Attack

Choking / Epigastric Mass

Odynophagia

Troublesome dysphagia, UNABLE TO EAT

unintentional Weight Loss

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10
Q

Non-Pharmacologic Treatment

for GERD

A

Weight Loss

  • if NOCTURNAL SYMPTOMS*
  • *6-8 Inches** of head of bed elevation
  • avoid meals* 2-3 hrs b4 bedtime

Other:
quit smoking
ID / avoid trigger foods
avoid lying down after eating
evaluate the medication list

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11
Q

Antacids

MoA / USE / DDIs

A

Neutralization of ACID
INCREASES LES Pressure

Used as an Add-On treatment
useful for daytime symptomatic relief
does NOT promote healing

Increase dose or change if symptoms >2 weeks

Drugs that require acidic environment

  • *Digoxin / Phenytoin / Isoniazin / Ketoconazole / IRON**
  • some CHELATION of* tetracyclines + fluorquinolones
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12
Q

Calcium Antacids

Important Notes

A

Tums / Rolaids / Caltrate

Antacid choice in PREGNANCY

Constipating

caution in RENAL IMPAIRMENT

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13
Q

Aluminum Antacids

Important Notes

A

Amphogel / AlternaGEl

Constipating

Accumilation in Renal Failure

Binds to –> phosphate –> hypoPHOSphatemia
–> anorexia/muscle weakness

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14
Q

Magnesium Antacids

Important Notes

A

Philips Milk of Magnesia

Diarrhea

Accumulation in Renal failure

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15
Q

Sodium Bicarbonate Antacids

Important Notes

A

Alka Seltzer

caution in _renal impairment_

sodium content -> edema / HTN / fluid retention

contains ASPIRIN
caution with warfarin / pregnant patients

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16
Q

Aluminum - Mg Antacids

Important Notes

A

Maalox / Mylanta / Riopan

DIARRHEA predominant
but EITHER can occur since:
Aluminum = Constipating /// Magnesium = Diarrhea

17
Q

Antacid + Alginic Acid

Important Notes

A

Gaviscon

Antirefluxant

Viscous solution FLOATS on water in the stomach
NOT FOR NIGHTIME USE
since it ONLY works in UPRIGHT position

take with full glass of water

18
Q

H2RA’s

Effectiveness / Etc

A

Longer ONSET + Duration vs antacids

used for ANTICIPATED REFLUX

healing rate better in mild reflux

Equivalent Efficacy BETWEEN PRODUCTS

ALL ARE RENALLY DOSED
CrCl

19
Q

Famotidine Dosing

H2RA for GERD

A

Pepcid
20-40mg PO BID

take before meals

CrCl <50 ml/min
reduce dose by 50% or QOD

20
Q

Ranitidine Dosing

H2RA for GERD

A

Zantac
150mg PO BID

IV dose = 50mg TID

CrCl < 50 ml/min

reduce dose by 50% or DAILY (instead of BID)

21
Q

PPI

Stuff

A

More effective > High Dose H2RAs but more expensive
Effective for Erosive / Non-Erosive Esophagitis

DO NOT CRUSH OR CHEW

Those with swallowing difficulties:
can sprinkle capsule on Food / use Liquid / IV

Equivalent Efficacy amoung products

Metabolism / Inhibiton VARIES by agent
CYP2C19 / CYP2C9 / CYP1A2 / CYP3A4

22
Q

PPI

General Dosing / Administration

A

EVERY DAY
30-60min BEFORE a meal
Deslansoprazole = can disregard meals
Omep = NaBicarb = administered RIGHT BEFORE BEDTIME

can increase to BID, 2nd dose taken 30-min b4 evening meal

Consider TAPERING / Discontinueing after 8 WEEKS

23
Q

PPI

ADR’s

A
  • *Generally WELL tolerated**
  • *GI Discomfort** = Constipation / NVD
  • *CNS** = HA / Dizziness
  • *Rare ADRs** seen in those with LONG-TERM therapy
  • *Pruritis / ^LFTs^**

Rebound ACID HYPERsecretion
related to the duration of treatment
–> TAPER off the PPI

24
Q

GERD Guidelines

A

TAKE FOR 8 WEEKS
initiate on QD Dosing

If there is a PARTIAL RESPONSE:
Adjust Admin timing
switch to a different PPI
Consider BID Dosing

  • if there is no response:*
  • *evaluation -> endoscopy**
25
Q

GERD Treatment

MAINTENENCE

A

Should still CONTINUE PPI Therapy in:

  • *Erosive / Barrett’s** Esophogitis
  • *Return of Symptoms** after the PPI is D/C or complications

Can use H2RA for those without erosive disease
use in BEDTIME in selective ptatients

  • NOT RECOMMENDED*
  • *prokinetic therapy +/- baclofen**

Always start on the lowest dose

26
Q

Metoclopramide
Reglan / Metozolv ODT

for GERD

A

NOT recommended as monotherapy for GERD
only in select SEVERE GERD patients

10mg PO QID
30-60 min b4 meals & HS

EPS (extrapyramidal symptoms)
Drowsiness/Fatigue / Diarrhea

Black blox warning = Tardive Dyskinesia TD

27
Q

Baclofen

for GERD

A

NOT recommended
but is used in REFRACTORY GERD

no long term data

limited use due to ADR’s
dizzy / somnolence / constipation

28
Q

Sucralfate / Carafate

for GERD

A

SAFE IN PREGNANCY

29
Q

BID PPI + H2RA HS

use for GERD

A

Twice a day dosing of PPI + Nightime H2RA

used for BREAKTHROUGH NOCTURNAL ACID SECRETION

prn basis

little evidence

30
Q

Best Practice Recommendations

for PPI Therapy for GERD

A

PERIODICALLY RE-EVALUATE
the dose / duration of PPI’s
use the LOWEST EFFECTIVE DOSE

Should NOT routinely use probiotics

Control their intake of calcium / B12 / MG

  • *should NOT screen/monitor**
  • *bone mineral density / SrCl / B12**
  • no evidence for or against testing them for this*
31
Q

LACTATION SAFETY

of GERD Treatments

A
  • *Antacids / Sucralfate**
  • minimal to NONE in milk, considered SAFE*
  • *H2RAs**
  • all have MINIMAL secretion, considered SAFE*
  • *PPIs**
  • limited info on these, safety is UNKNOWN, except:*

omeprazole + pantoprazole = considered SAFE

32
Q

Esomeprazole Formulations

A

DR Caps
20 / 40mg

DR Suspension
10 / 20 / 40mg packets

IV Solution
20 / 40mg vials

33
Q

Omeprazole Formulations

A

DR Caps
10 / 20 / 40mg

DR TABS
20 mg

IR Suspension
20 / 40 mg packets

Omeprazole + Sodium Bicarb = ZEGERID
20 / 40mg + 1100mg
or Suspension of 20/40 + 1680mg

34
Q

Lansoprazole Formulations

A

DR Caps
15 / 30 mg

DR DISINTEGRATING TABLET
15 / 30 mg

Suspension
3mg/mL powder

PDAT2 (22 decks)

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