26 - GERD Flashcards
Pathophysiology of GERD
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
Medical / Surgical Factors
that may Precipitate GERD
Pregnancy
Asthma
Scleroderma (hardening of tissues)
Gastroparesis = slow motility of gut
Zollinger - Ellison Syndrome
Nasal Tube Intubation
MEDICATIONS
that cause a DECREASED LES Pressure
Anti-Cholinergics / Serotonin Antagonist
Barbiturates / GABA Agonist
Caffeine / coffee / Alcohol
Dopamine / Estrogen / Progestrone
Morphine / Ethanol / Nicotine
Tetracycline / theophylline / Nitrates
MEDICATIONS
that are DIRECT Mucosal irritants
GERD
Alendronate
ASA / NSAIDs
IRON
Quinidine / Potassium-Chloride
spicy foods / citrus / tomato / COFFEE
Esophageal Symptoms of GERD
HEARTBURN
pyrosis
Regurgitation
reflux
- *Dysphagia
- difficulty swallowing***
Nausea
EXTRA-Esophageal
Symptoms of GERD
caused by GERD –> affects other areas
CHEST Pain
Cough
Asthma Worsening
Laryngitis
Typical / A-Typical
Symptoms of GERD
TYPICAL
Heartburn / HyperSALVation / Belching / Regurgitation
A-Typical
Hoarseness / Dental Erosions
Non-allergic Asthma / Chronic COguh
Pharyngitis / Chest Pain
Patient Characteristics or Complications
ALARM SYMPTOMS
When to Refer to MD for GERD
Pregnant / Elderly / Infants
History of:
GI Disorders / IBD / PUD
Complications:
Barrett’s Esophagitis
Esophageal Cancer
if alarm symptoms –> refer for ENDOSCOPY
BLOOD IN GENERAL
ALARM SYMPTOMS
When to Refer to MD for GERD
Anemia / GI Bleeding / Vomitting
= BLOOD IS BAD
Chest pain = Heart Attack
Choking / Epigastric Mass
Odynophagia
Troublesome dysphagia, UNABLE TO EAT
unintentional Weight Loss
Non-Pharmacologic Treatment
for GERD
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
Antacids
MoA / USE / DDIs
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
Calcium Antacids
Important Notes
Tums / Rolaids / Caltrate
Antacid choice in PREGNANCY
Constipating
caution in RENAL IMPAIRMENT
Aluminum Antacids
Important Notes
Amphogel / AlternaGEl
Constipating
Accumilation in Renal Failure
Binds to –> phosphate –> hypoPHOSphatemia
–> anorexia/muscle weakness
Magnesium Antacids
Important Notes
Philips Milk of Magnesia
Diarrhea
Accumulation in Renal failure
Sodium Bicarbonate Antacids
Important Notes
Alka Seltzer
caution in _renal impairment_
sodium content -> edema / HTN / fluid retention
contains ASPIRIN
caution with warfarin / pregnant patients
Aluminum - Mg Antacids
Important Notes
Maalox / Mylanta / Riopan
DIARRHEA predominant
but EITHER can occur since:
Aluminum = Constipating /// Magnesium = Diarrhea
Antacid + Alginic Acid
Important Notes
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
H2RA’s
Effectiveness / Etc
Longer ONSET + Duration vs antacids
used for ANTICIPATED REFLUX
healing rate better in mild reflux
Equivalent Efficacy BETWEEN PRODUCTS
ALL ARE RENALLY DOSED
CrCl
Famotidine Dosing
H2RA for GERD
Pepcid
20-40mg PO BID
take before meals
CrCl <50 ml/min
reduce dose by 50% or QOD
Ranitidine Dosing
H2RA for GERD
Zantac
150mg PO BID
IV dose = 50mg TID
CrCl < 50 ml/min
reduce dose by 50% or DAILY (instead of BID)
PPI
Stuff
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
PPI
General Dosing / Administration
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
PPI
ADR’s
- *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
GERD Guidelines
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**
GERD Treatment
MAINTENENCE
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
Metoclopramide
Reglan / Metozolv ODT
for GERD
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
Baclofen
for GERD
NOT recommended
but is used in REFRACTORY GERD
no long term data
limited use due to ADR’s
dizzy / somnolence / constipation
Sucralfate / Carafate
for GERD
SAFE IN PREGNANCY
BID PPI + H2RA HS
use for GERD
Twice a day dosing of PPI + Nightime H2RA
used for BREAKTHROUGH NOCTURNAL ACID SECRETION
prn basis
little evidence
Best Practice Recommendations
for PPI Therapy for GERD
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*
LACTATION SAFETY
of GERD Treatments
- *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
Esomeprazole Formulations
DR Caps
20 / 40mg
DR Suspension
10 / 20 / 40mg packets
IV Solution
20 / 40mg vials
Omeprazole Formulations
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
Lansoprazole Formulations
DR Caps
15 / 30 mg
DR DISINTEGRATING TABLET
15 / 30 mg
Suspension
3mg/mL powder
