8 - Dyspepsia & GERD Flashcards
Where do symptoms of dyspepsia originate?
Gastroduodenal area
What are common symptoms of dyspepsia?
- Pain/burning
- Postprandial fullness
- Early satiety
What is a common term for dyspepsia?
Indigestion
Is dyspepsia a diagnosis?
No, its a categorization of symptoms that may vary between patients and may or may not have pathological causes
What is organic dyspepsia?
Identifiable causes/structural abnormalities
What are some causes of organic dyspepsia?
- PUD
- Reflux esophagitis
- Gastric/esophageal cancer
- Medications (erythromycin, NSAIDs, garlic, white willow)
- Infections
What is functional dyspepsia?
- No identifiable cause or structural abnormalities
- Also called idiopathic or non-ulcer
- Thought to be due to psychological factors, GI motility and organ sensory dysfunction
What are the different categories of dyspepsia symptoms?
- Reflux-like
- Ulcer-like
- Dismotility
What are the different classifications of dyspepsia and GERD symptoms?
- Frequent – 2 or more days per week
- Episodic – mild and sporadic symptoms which are usually predictable
- Persistent/chronic – occurs over long periods (over 3 months)
What are the ALARM symptoms of dyspepsia and GERD?
- Chest/cardiac pain (pain radiating to arm and/or neck, jaw, or back; pain occurs w/ exercise)
- Dysphagia or odynophagia (difficulty or pain when swallowing)
- Choking/globus sensation
- Upper GI bleeding (vomiting blood, or black, tarry stools)
- Persistent vomiting
- Unexplained or involuntary weight loss
What are some red flags for dyspepsia and GERD?
- ALARM symptoms
- Dental erosions
- Pain unrelated to meals
- Persistent nausea or diarrhea
- Children
- Symptoms recurring or prolonged over 3 months
- Sx occur or continue after taking OTC tx for 2 weeks
- Px over 50 y/o w/ no known cause or worsening of sx
- Px on long-term NSAIDs
- History of upper GI cancer or PUD
What are common symptoms of GERD?
- Frequent regurgitation of stomach acid or burning feeling in stomach or esophagus
- Hypersalivation
- Non-cardiac chest pain
- Burping and belching
- Worsens when px bends over or lays down
- Occurs w/in 1-2 hours after eating
What is GERD described as?
Heartburn
What is the difference between GERD and normal reflux?
GERD occurs when reflux becomes bothersome and/or inflicts structural damage to esophagus
What are potential causes of GERD?
- Defective lower esophageal sphincter
- Hiatal hernia
- Impaired esophageal peristalsis
- Delayed gastric emptying
- Excessive gastric acid production
- Bile reflux
What must occur with respect to the lower esophageal sphincter for GERD to occur?
Pressure gradient between LES and stomach must be less than normal or absent
What are some contributing factors to GERD and dyspepsia?
- Foods that decrease LES tone (alcohol, carbonated beverages, chocolate, caffeinated beverages, foods w/ high fat and sugar, garlic, onions, peppermint, spearmint)
- Foods that exert a direct irritant effect (citrus, coffee, spicy foods, tomatoes)
- Pregnancy
- Lifestyle (obesity, smoking, diet)
- Over 65 y/o
- Medications (anticholinergics or drugs w/ anticholinergic side effects decrease LES tone; antibiotics and NSAIDs exert a direct irritant effect)
- Disease status
- Posture
- Stress and anxiety
Do symptoms of GERD correlate to the severity of structural esophageal damage?
No
What are differential diagnoses of GERD and dyspepsia?
- IBS
- Peptic ulcer
- Gastric and pancreatic cancer
- Angina
- MI
- Gallstones
- Asthma
What are the goals of treatment for dyspepsia and GERD?
- Relieve symptoms
- Prevent recurrence of symptoms
- Heal esophageal mucosa
- Improve quality of life
- Prevent complications
What are some non-pharms for dyspepsia and GERD?
- Smaller, more frequent meals
- Quit smoking
- Decrease caffeine and alcohol intake
- Decrease fat intake
- Avoid exercising for 3 hours after eating or bending on a full stomach
- Avoid lying down right after eating
What is the initial treatment for mild or intermittent GERD in the absence of ALARM symptoms?
Diet and lifestyle modifications
What are the 3 categories of pharmacological options for GERD and dyspepsia?
- Symptom relief (antacids, foaming agents, antiflatulents)
- Symptom relief and prevention (H2 receptor antagonists)
- Prevention and symptom relief (proton pump inhibitors)
How long does it take for antacids to provide symptomatic relief?
About 5 minutes
How long do antacids last?
- Less than 1 hour if given w/o food
- 1-3 hours if given after food
What is Acid Neutralizing Capacity (ANC)?
- Amount of acid buffered / dose over a specified period
- Determines dosing equivalents between antacids
How are antacids dosed?
As needed after meals and at bedtime
What are the potencies of antacids from highest to lowest?
- Calcium carbonate
- Sodium bicarbonate
- Magnesium salts
- Aluminum hydroxide
Are suspensions or solid dosage forms preferred for antacids?
Suspensions
What is the most common side effect of magnesium antacids?
Diarrhea
When should magnesium antacids be avoided?
- Elderly
- Renal failure
- Unknown in pregnancy; safe in breast feeding
What are some side effects of aluminum based antacids?
- Constipation
- Hemorrhoids
- Osteomalacia and osteoporosis
What are some precautions of aluminum based antacids?
- Avoid long term use in renal dysfunction
- Avoid in px prone to constipation
- Caution in elderly
- Unknown in pregnancy; safe in breastfeeding
What are some side effects of calcium carbonate antacids?
- Constipation, belching, flatulence
- Rebound acidity
- High doses can cause hypercalcemia and milk-alkali syndrome
- Kidney stones
What are some precautions of calcium carbonate antacids?
- Preferred agent in renal dysfunction
- Caution if px has high Ca intake
- Safe in pregnancy and breastfeeding
What are some side effects of sodium bicarbonate antacids?
- Ingestion after large meal can cause gastric detention
- Belching and flatulence
What are some precautions of sodium bicarbonate antacids?
- Avoid in px w/ restricted sodium intake
- Avoid in pregnancy
- Not recommended during breastfeeding
Antacids interact w/ drugs via _____
- Interfere w/ absorption by increasing gastric pH
- Interfere w/ elimination by increasing urine pH
- Alteration to GI transit time
What are the main drug interactions w/ antacids?
- Enteric coated and buffered products
- Antibiotics (tetracyclines, fluoroquinolones, azithromycin)
- Iron and digoxin
What should be recommended w/ respect to medications and antacids?
Don’t take any other oral medication w/in 2 hours of antacids
What is the mechanism of action for foaming agents?
- Alginates precipitate in acid medium of stomach to form sponge-like matrix of alginic acid
- Bicarbonate reacts w/ gastric acid to form CO2 which is trapped in matrix and helps it float, allowing it to act as a barrier between the stomach and esophagus
Do foaming agents neutralize acid?
No
What are foaming agents available as?
Combination of alginic acid and an antacid
What is the onset and duration of foaming agents?
- Onset = minutes
- Duration = about 4 hours
How are foaming agents ingested?
- Chew tablet and drink glass of water immediately after
- Only works if px is upright
What are some side effects to foaming agents?
- Nausea and vomiting
- Flatulence and belching
What is the most common drug interaction w/ foaming agents?
Simethicone
What are some precautions to foaming agents?
- Only use in adults
- Compatible w/ pregnancy and lactation
Why is bismuth subsalicylate not recommended for treatment of dyspepsia and GERD?
Contains salicylate (aspirin) which can cause these symptoms and irritate the stomach
What is bismuth subsalicylate used for?
- Treatment of overindulgence of food and alcohol
- Diarrhea
- Eradication of H. pylori in combination w/ other agents
What are some side effects of bismuth subsalicylate?
- Darkening of tongue
- Gray-black stools
- Bismuth toxicity
- Tinnitus
What are some precautions for bismuth subsalicylate?
- Avoid use in young children and px w/ bleeding disorders
- Avoid in px on medications that may interact w/ salicylates
- Do not use during pregnancy or lactation
What is the method of action of simethicone?
- Decrease surface tension of gas bubbles in stomach and intestine
- Gas bubbles broken and eliminated more easily
Simethicone is often added to products with _____
Antacids
What is the onset and duration of simethicone?
- Onset about 15 minutes
- Duration about 3 hours
When should simethicone be ingested?
After meals and at bedtime
What are the side effects of simethicone?
No known
Who can take simethicone?
- Infants and adults
- Pregnant and breastfeeding women
Who shouldn’t take simethicone?
Px w/ suspected intestinal perforation or obstruction
What is the mechanism of action of histamine 2 receptor antagonists (H2RA)?
- Competitively and reversibly bind to H2 receptors in gastric parietal cells
- Dose-dependent inhibition of gastric acid secretion
- Inhibits basal and nocturnal gastric acid secretion more than meal stimulated acid secretion
What is the onset and duration of H2RA?
- Onset = 30-60 minutes
- Duration = 6-8 hours depending on dose
What are the chemical names of H2RA?
Ranitidine and famotidine
What is the dosing of H2RA for prevention?
- Ranitidine 75-150 mg 30-60 minutes before meals
- Famotidine 10 mg 10-15 minutes before meals
What is the dosing of H2RA for treatment in adults?
- 1 tablet BID
- Second dose can be taken 1 hour after 1st dose if 1st dose is ineffective
Does food affect the bioavailability of H2RA?
No
What are the side effects of H2RA?
- Nausea, vomiting, diarrhea
- Headache, drowsiness, dizziness
Which medication affects H2RA?
Antacids, so don’t take antacids w/in 0.5-1 hour of H2RA ingestion
What medications do H2RA interact w/?
- Iron
- Intraconazole
- Ketoconazole
- Sulcralfate
What ages are recommended for H2RA?
- Ranitidine over 16
- Famotidine over 12
Are H2RA safe in pregnancy?
Yes
What are the chemical names of PPI’s?
Omeprazole and esomeprazole
What are PPI’s used for?
Treatment of frequent heartburn for patients who have symptoms 2 or more days per week
What is the mechanism of action for PPI’s?
Inhibits hydrogen potassium ATPase (proton pump), which irreversibly blocks the final step of gastric acid secretion
What is the onset of PPI’s?
About 2-3 hours, but complete relief may take 1-4 days
What is the dosing of PPI’s?
- Omeprazole – 1 tablet (20 mg) 30-60 mins before eating every morning for 14 days; may be repeated after 4 months if symptoms recur
- Esomeprazole – 18 years and older, 20 mg w/ water every morning before eating for 14 days; may be repeated after 4 months
When should you refer a patient that is taking PPI’s?
If symptoms persist for more than 2 weeks or recur w/in 4 months
What drugs do PPI’s interact w/?
CYP 2C19 and may decrease absorption of pH-dependent drugs
What are some side effects of short time use of PPI’s?
Diarrhea, constipation, headache
What are some side effects of long time use of PPI’s?
- Increased risk of osteoporosis or bone fracture
- C. difficile infections
When should H2RA’s be used?
Patients w/ predictable pattern of symptoms
When should antacids be used?
Patients who need immediate relief or have unpredictable pattern of symptoms
What is the maximum length of self-treatment?
14 days
Which antacid is preferred for pregnancy?
Calcium carbonate
Which H2RA and PPI are preferred for pregnancy?
Ranitidine and omeprazole
What should be monitored while on therapy for dyspepsia or GERD?
- Monitor daily for side effects and hypersensitivity
- Monitor symptoms daily as well as regularly over long term
What are red flags for dyspepsia and GERD after treatment has been completed?
- Symptoms lasting over 2 weeks
- Symptoms worsen or are unrelieved by drug therapy
- Development at any time of ALARM or atypical symptoms
- Symptoms recurring 2-3 times per year
