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63: GERD Flashcards

1
Q

GERD

A

-reflux tummy contents into esophagus or lung

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2
Q

GERD epidemiology

A

-pt 50 and older
-20% of US adults
-prevalence of erosive esophagitis, barret’s esophagus and adenocarcinoma higher in men

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3
Q

Contributing factors to GERD

A

-pregnancy
-obesity
-tobacco smoking
-gene predisposition
-alcohol consumption
-triggering meds and food

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4
Q

GERD patho

A

-abnormal esophageal clearance
-dec LES pressure
-emptying + ab pressure
-acid pocket formation
-mucosal resistance

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5
Q

Foods that dec LES pressure

A

-fat
-mint
-chocolate
-coffe, soda, tea
-garlic
-onions
-chili peppers
-alcohol

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6
Q

Foods that are direct irritants for GERD

A

-spicy
-orange juice
-tomato juice
-coffe
-tobacco

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7
Q

Meds that dec LES pressure

A

-anticholinergics
-barbituates
-caffeine
-DHP
-Dopamine
-estorgen/progesterrone
-nictotine
-nitrates
-tetracycline

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8
Q

Meds that are direct irritant to GERD

A

-arpirin
-bisphosphonates
-NSAIDs
-iron
-quinidine
-potassium chloride

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9
Q

GERD presentation

A

-symptom based + esophageal injury
-extraesophageal

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10
Q

Symptom-based GERD presentation

A

-heartburn
-regurgitation and belching
-reflux chest pain

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11
Q

Extraesophageal GERD presentation

A

-chronic cough
-laryngitis
-wheezing
-asthma

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12
Q

GERD alarm symptoms

A

-dysphagia
-odynophagia
-bleeding
-weight loss

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13
Q

Diagnosing GERD

A

-Upper endoscopy
-Ambulatory reflux monitoring
-Manometry/Pressure Topography
-Barium Radiography

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14
Q

Upper Endoscopy

A

-preferred
-indicated for presistent GERD, alarm symptoms, barrets, pH, endoscopic procedures

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15
Q

Ambulatory reflux monitory +/- impedance

A

-useful for pts not responding to acid suppression therapy when endoscopy is normal or extraesophageal symptoms
-asses exposure time
AET: 0<4% is normal >6% is abnormal

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16
Q

Manometry/High-res esophageal topography

A

-useful in those who failed BID PPI therapy w normal endoscopic findings

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17
Q

Barium Radiography

A

-useful in detecting hiatal hernia
-not routinely used to diagnose GERD bc it lack sensitivity and specificity

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18
Q

Complications of GERD

A

-erosive esophagitis
-stricture
-barret’s esophagus
-adenocarcinoma

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19
Q

GERD goals of care

A

-relieve symptoms
-dec freq of acid reflux
-promote healing of injured mucosa
-prevent complications related to GERD

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20
Q

GERD treatment overview

A
  1. Lifestyle
  2. PRN rxs (antacids and H2RAs
  3. scheduled rxs (H2Ras and PPIs)
  4. Surgery
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21
Q

Lifestyle modifications

A

-weight loss
-sleep w head elevated
-avoid late meals
-avoid triggers
-portion control
-exercise

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22
Q

Treat GERD OTC when

A

-no alarm symptoms
-mild-moderate
-new onset
-identifiable triggers minimized

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23
Q

When to refer GERD

A

-alarm symptoms
-OTC trial for 14 days w no relief

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24
Q

Antacids timing

A

-onset 5 min
-works for 30-60 min
-neutralize acid

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25
Antacid side effects
-nausea, vomiting, flatulence -mg: diarrhea -Ca and Al: constipation
26
Antacid drug interaction
-tetracycline -fluoroquinolones -levothyroxine -digoxin -azole antifungals -steroids -iron -HIV medications -takes meds 2 hours before or after antacids
27
Antacid drugs
-Tums (calcium carb) -Milk of Magnesia (mg hydroxide) -Maalox (al + mg +/- simethicone) -Gaviscon (al + mg + alginate) -Rolaids (Ca+Mg) -Alkaseltzer GAS(Ca + simethicone) -alkaseltzer (sodium bicarbonate + aspirin + citric acid) -pepto-bismol (bismuth subsalicylate) -Gas-X (simethicone)
28
Tums doing
-2-4 tablets PRN upto QID -max 16/day
29
Milk of Magnesia dosing
-5-15 mL PRN upto QID -max 60mL/day
30
Maalox dosing
-10-20mL PRN or at meals and bedtime upto QID -max 80mL/day
31
Gaviscon dosing
-2-4 tablets or 10-20mL at meals and bedtime QID -max 16/day
32
H2RA info
-reversible inhibition of H2 in parietal cells -onset 60 min -last 4-6 hours
33
H2RA drugs
-Famotidine (Pepcid, Zantac) -Cimetidine (Tagamet)
34
Famotidine dosing
-OTC: 10-20mg BID max 40 -rx: 10mg BID pRN 10-60 min before meals -inc dose to 20mg BID for 2 weeks if no improvement after 2-4 weeks -if symptoms persist consider PPI -renal adjustment! give 50% of dose if CrCl is UNDER 50ml/min
35
Cimetidine (Tagamet) dosing
-OTC and RX: 200mg qd up to 30 min before meals max 400 -only reduce dose in severe kidney impairment
36
Cimetidine (tagamet) interactions
-many drug-drug interactions via CYP1A2, 2C9, 2D6, 3A4
37
H2RA side effects
-headache -dizziness/fatigue -constipation OR diarrhea -somnolence/confusion -agitation -B12 deficicency
38
H2RA clinical pearls
-AVOID in pt at risk of delirium -use alone or in combo w other classes to treat mild-moderate GERD -all H2RAs are equally efficacious -not as effective as PPIs
39
PPIs info
-irreversible inhibition of H/K ATPase -onset 2-3 hours -lasts 24 hours
40
PPI drugs
-Omeprazole -Pantoprazole -Esomeprazole -Lansoprazole -Dexlansoprazole -Rabeprazole
41
Omeprazole (prilosec)
-OTC: 20mg qd for 14 days -Rx: 10-40mg qd -no renal dose adjustments -take 30-60min before first meal -metabolized by CYP2C19
42
Pantoprazole (protonix)
-PO rx: 20-40mg qd -IV rx: 40 mg qd -no renal adjustment -admin 60 minutes before first meal of the day
43
Esomeprazole
-OTC: 20mg qd for 14 days repeat in 4 months -PO and IV rx: 20-40mg qd -no renal dose adjustment -admin 30-60 min before first meal of day -metabolized by CYP1C19
44
Lansoprazole (Prevacid)
-OTC 15 mg qg for 14 days repeat in 4 months -Rx: 15-30mg qd -no renal dose adjustments -orally disintegrating tablet (ODT) -admin 30-60 min before first meal of day
45
Dexlansoprazole (dexilant)
-rx only: no complications at 30 mg but some at 60mg -60mg qd for 8 weeks then. 30mg indefinitely -no adjustment -dual release onset at 1-2 hours and again at 4-5 hours -can take w/o regard to meals
46
Rabeprazole (Aciphex)
-Rx: 10-20mg qd -no adjustments -admin 30 min before first meal
47
PPI short term side effects
-headache -dizziness -diarrhea -nausea -ab pain -infection -pneumonia
48
Long term side effects of PPIs
-hypomagnesemia -bone density dec/fractures -vit B12 deficiency -chronic kidney disease
49
PPI drug interactions
-inc effect of methotrexate, phenytoin, warfarin -dec effect of iron, bisphosphonates, HIV, HCV drugs, clopidogrel -PPIs are CYP2C19 inhibits (omeprazole and esomeprazole strongest)
50
PPI clinical pearls
-tx should not last more than 8 weeks on Rx and 14 days on OTC -max therapy by inc dose, freq, or switching -Beer's criteria -recommended taper after long term therapy
51
Promotility agents
-metoclopramide -bethanechol -may be useful as adjunct therapy if no known motility defect -agents are NOT as effective as acid suppressino therapy and have undesirable side effects
52
Mucosal protectant (sucralfate)
-limit use in tx of GERD but could manage radiation esophagitis and nonacid reflux GERD
53
Combination therapies for GERD
-Antacids + H2RAs -PPIs + H2RAs
54
Antacid + H2RA combo
-may be helpful for heartburn after meals -PEPCID AC (famotidine + ca carbonate + magnesium)
55
PPIs + H2RAs
-nighttime dose of H2RA can help w overnight acid production -can provide breakthrough relief in patients on PPI
56
Surgical management of GERD
-Antireflux surgery -reinforces lower esophageal sphincter -reduces regurgitation and acid back-flow
57
GERD treatment in pregnancy
1. Lifestyle 2. Antacids w/o aspirin 3. H2RAs 4. PPis only if severe
58
GERD symptoms in infants and children
-refusing to eat -wheezing, cough -dental erosion -recurrent regurgitation -irritability
59
GERD alarm symptoms in kids
-weight loss -fever -seizure -persistent vomiting and diarrhea
60
Non-pharm options for GERD in kids
-thickening formula/foods -dec volume of intake -milk free -positioning therapy
61
Pediatric treatment of GERD
-PPIs and H2RAs for 4-8 weeks for DIAGNOSED gerd -Antacids not chronically and dont use Al or bismuth subsalicylate antacids in kids under 12 -simethicone and probiotics -ginger, chamomile, peppermint

Therapeutics (78 decks)

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