63: GERD Flashcards
GERD
-reflux tummy contents into esophagus or lung
GERD epidemiology
-pt 50 and older
-20% of US adults
-prevalence of erosive esophagitis, barret’s esophagus and adenocarcinoma higher in men
Contributing factors to GERD
-pregnancy
-obesity
-tobacco smoking
-gene predisposition
-alcohol consumption
-triggering meds and food
GERD patho
-abnormal esophageal clearance
-dec LES pressure
-emptying + ab pressure
-acid pocket formation
-mucosal resistance
Foods that dec LES pressure
-fat
-mint
-chocolate
-coffe, soda, tea
-garlic
-onions
-chili peppers
-alcohol
Foods that are direct irritants for GERD
-spicy
-orange juice
-tomato juice
-coffe
-tobacco
Meds that dec LES pressure
-anticholinergics
-barbituates
-caffeine
-DHP
-Dopamine
-estorgen/progesterrone
-nictotine
-nitrates
-tetracycline
Meds that are direct irritant to GERD
-arpirin
-bisphosphonates
-NSAIDs
-iron
-quinidine
-potassium chloride
GERD presentation
-symptom based + esophageal injury
-extraesophageal
Symptom-based GERD presentation
-heartburn
-regurgitation and belching
-reflux chest pain
Extraesophageal GERD presentation
-chronic cough
-laryngitis
-wheezing
-asthma
GERD alarm symptoms
-dysphagia
-odynophagia
-bleeding
-weight loss
Diagnosing GERD
-Upper endoscopy
-Ambulatory reflux monitoring
-Manometry/Pressure Topography
-Barium Radiography
Upper Endoscopy
-preferred
-indicated for presistent GERD, alarm symptoms, barrets, pH, endoscopic procedures
Ambulatory reflux monitory +/- impedance
-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
Manometry/High-res esophageal topography
-useful in those who failed BID PPI therapy w normal endoscopic findings
Barium Radiography
-useful in detecting hiatal hernia
-not routinely used to diagnose GERD bc it lack sensitivity and specificity
Complications of GERD
-erosive esophagitis
-stricture
-barret’s esophagus
-adenocarcinoma
GERD goals of care
-relieve symptoms
-dec freq of acid reflux
-promote healing of injured mucosa
-prevent complications related to GERD
GERD treatment overview
- Lifestyle
- PRN rxs (antacids and H2RAs
- scheduled rxs (H2Ras and PPIs)
- Surgery
Lifestyle modifications
-weight loss
-sleep w head elevated
-avoid late meals
-avoid triggers
-portion control
-exercise
Treat GERD OTC when
-no alarm symptoms
-mild-moderate
-new onset
-identifiable triggers minimized
When to refer GERD
-alarm symptoms
-OTC trial for 14 days w no relief
Antacids timing
-onset 5 min
-works for 30-60 min
-neutralize acid
Antacid side effects
-nausea, vomiting, flatulence
-mg: diarrhea
-Ca and Al: constipation
Antacid drug interaction
-tetracycline
-fluoroquinolones
-levothyroxine
-digoxin
-azole antifungals
-steroids
-iron
-HIV medications
-takes meds 2 hours before or after antacids
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)
Tums doing
-2-4 tablets PRN upto QID
-max 16/day
Milk of Magnesia dosing
-5-15 mL PRN upto QID
-max 60mL/day
Maalox dosing
-10-20mL PRN or at meals and bedtime upto QID
-max 80mL/day
Gaviscon dosing
-2-4 tablets or 10-20mL at meals and bedtime QID
-max 16/day
H2RA info
-reversible inhibition of H2 in parietal cells
-onset 60 min
-last 4-6 hours
H2RA drugs
-Famotidine (Pepcid, Zantac)
-Cimetidine (Tagamet)
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
Cimetidine (Tagamet) dosing
-OTC and RX: 200mg qd up to 30 min before meals max 400
-only reduce dose in severe kidney impairment
Cimetidine (tagamet) interactions
-many drug-drug interactions via CYP1A2, 2C9, 2D6, 3A4
H2RA side effects
-headache
-dizziness/fatigue
-constipation OR diarrhea
-somnolence/confusion
-agitation
-B12 deficicency
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
PPIs info
-irreversible inhibition of H/K ATPase
-onset 2-3 hours
-lasts 24 hours
PPI drugs
-Omeprazole
-Pantoprazole
-Esomeprazole
-Lansoprazole
-Dexlansoprazole
-Rabeprazole
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
Pantoprazole (protonix)
-PO rx: 20-40mg qd
-IV rx: 40 mg qd
-no renal adjustment
-admin 60 minutes before first meal of the day
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
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
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
Rabeprazole (Aciphex)
-Rx: 10-20mg qd
-no adjustments
-admin 30 min before first meal
PPI short term side effects
-headache
-dizziness
-diarrhea
-nausea
-ab pain
-infection
-pneumonia
Long term side effects of PPIs
-hypomagnesemia
-bone density dec/fractures
-vit B12 deficiency
-chronic kidney disease
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)
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
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
Mucosal protectant (sucralfate)
-limit use in tx of GERD but could manage radiation esophagitis and nonacid reflux GERD
Combination therapies for GERD
-Antacids + H2RAs
-PPIs + H2RAs
Antacid + H2RA combo
-may be helpful for heartburn after meals
-PEPCID AC (famotidine + ca carbonate + magnesium)
PPIs + H2RAs
-nighttime dose of H2RA can help w overnight acid production
-can provide breakthrough relief in patients on PPI
Surgical management of GERD
-Antireflux surgery
-reinforces lower esophageal sphincter
-reduces regurgitation and acid back-flow
GERD treatment in pregnancy
- Lifestyle
- Antacids w/o aspirin
- H2RAs
- PPis only if severe
GERD symptoms in infants and children
-refusing to eat
-wheezing, cough
-dental erosion
-recurrent regurgitation
-irritability
GERD alarm symptoms in kids
-weight loss
-fever
-seizure
-persistent vomiting and diarrhea
Non-pharm options for GERD in kids
-thickening formula/foods
-dec volume of intake
-milk free
-positioning therapy
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
