Dyspepsia Flashcards
What is Dyspepsia
Is a term used to describe a complex of upper GI tract symptoms typically present for four or more weeks including:
- Upper abdominal pain or discomfort (e.g. bloating, belching, a feeling of abnormal or slow digestion, early satiety)
- Heartburn, acid reflux (*more likely to be GORD if these predominate)
- Nausea and / or vomiting
What are the 3 causes/ triggers for Dyspepsia
- underlying conditions.
- drug induced
- lifestyle related
Give some examples of underlying conditions that can cause dyspepsia
- GORD
- Peptic Ulcer Disease
- Functional dyspepsia
- Barrett’s oesophagus
- Upper GI malignancy
Give some examples of drug induced dyspepsia.
- Aspirin
- NSAIDs
- Corticosteroids (e.g. prednisolone
- Beta-blockers
- Benzodiazepines
Give some examples of lifestyle related tiggers
- trigger foods, Binge eating, Fatty foods
- Alcohol
- Caffeine
- Stress
- Obesity
- Smoking
Diagnosis - community pharmacy
- Offer initial and ongoing help
- lifestyle advice
- help with prescribed drugs
- OTC meds
- advice when to see GP
Alarm features of dyspepsia
- Dysphagia
- Haematemesis (vomit blood) or blood in stool
- Unexplained weight or appetite loss
- Upper abdominal mass
- Family history of GI malignancy
- Patients >55 years with any of the above OR any of the following:
- Change in bowel habit
- Treatment-resistant dyspepsia
- Dyspepsia with raised platelets or low haemoglobin
- Pain radiating to jaw, back, arm - ?CV cause
1st line Community Pharmacy Treatment Options
- Antacids: Alkaline, neutralise acid OR Alginates: Form a ‘raft’
Cautions: - Care with sugar (diabetics), Care with sodium content
(Renal impairment, hypertension /CVD, pregnancy)**
Side-effects: - Aluminium-based: constipation
- Magnesium-based: diarrhoea
Interactions: - May impair absorption of other medicines
- Can damage ‘enteric’ coat
2nd line Community Pharmacy Treatment Options
- PPI, e.g. Nexium control (esomeprazole)
- H2 receptor antagonists, e.g. Zantac (ranitidine) not currently available
Dyspepsia: Diagnosis (other settings)
- Clinical history
- Physical examination / investigations
- Referral for further specialist investigation (e.g. gastroenterologist)
Dyspepsia Management: Unidentified cause
- Non-pharmacological - Offer lifestyle & self-care advice
Pharmacological - Review existing medication, deprescribe (reduce or stop) causative drugs if appropriate
- 1st line: Full dose proton-pump inhibitor (PPI) for 4 weeks or H. pylori test & treat
- 2nd line: Histamine (H2) receptor antagonist (after considering further investigation)
How do proton pump inhibitors work?
Mechanism:
- Inhibits H+/K+ ATPase pump, therefore reducing gastric acid production
What is the PPI dosing for Dyspepsia ?
- Omeprazole 20mg OD OR
- Lansoprazole 30mg OD for 4 weeks. Step down/PRN PPI or self-care
What are some PPI Cautions/ side effects
- elderly
- may mask symptoms of gastric cancer
- Diarrhoea (including C. difficile risk, microscopic colitis)
headaches, dizziness - Electrolyte disturbances, especially hyponatraemia, hypomagnesia
- Fracture risk
PPI interactions
- clopidogrel (use lansoprazole / pantoprazole), citalopram
why do PPI need reviewed
- Due to concerns of long-term use, should aim to step-down to minimum dose that controls symptoms & trial stopping or PRN use (are some exceptions, e.g. Barrett’s Oesophagus)
How do istamine (H2) Receptor Antagonists work
- Mechanism: binds histamine receptor preventing histamine-mediated stimulation of gastric acid secret
- Review: as per PPI, aim to step down & where possible stop / PRN use
What are the cautions/ side effects of Histamine (H2) Receptor Antagonists
- Renal impairment (dose reduction)
- Pregnancy and breastfeeding (avoid)
- May mask the symptoms of gastric cancer
- Constipation, diarrhoea, dizziness, fatigue, headache, myalgia are common side effects
H2 Receptor Antagonists interactions
Cimetidine is a CP450 enzyme inhibitor and will increase the levels of many drugs; care with narrow therapeutic index medicines, e.g. phenytoin, theophylline, aminophylline, warfarin
Helicobacter pylori diagnoses and management
- Diagnosis: Stool antigen test (now preferred in primary care) or urea breath test
- Management: Aggressive triple-therapy of 2 antibiotics plus twice daily PPI for 7 days. Adherence is critical to successful eradication
- When choosing triple therapy regimen consider
Allergies
Drug interactions (mainly clarithromycin)
Previous antibiotic exposure
Patient compliance +++++++
What is functional Dyspepsia
- Thought to be a disorder of gut:brain interaction which may lead to symptoms via alterations in processes including:
- GI motility
- gut microbiota composition
- gastric acid secretion
- Diagnosis of exclusion, patients will normally have extensive investigation, including specialist assessment, e.g. for endoscopy
Functional dyspepsia: Management
- Non-pharmacological management as per unidentified cause dyspepsia
- H. pylori test and treat (if needed)
- If H. pylori has been excluded and symptoms persist, offer low-dose PPI (e.g. lansoprazole 15mg OD, omeprazole 10mg OD) or H2RA for 4 weeks then on an ‘as needed’ base
- If symptoms continue or recur after initial treatment, use PPI or H2RA at lowest dose possible to control symptoms
- Avoid long-term, frequent dose, continuous antacid therapy (only relieves symptoms, won’t prevent)
- May be a role for psychological therapies (e.g. CBT) or antidepressants, e.g. low dose amitriptyline
GORD Management ?
- Proven GORD’ refers to endoscopy-confirmed reflux disease. May be due to:
- Oesophagitis = oesophageal inflammation and mucosal erosions seen on test
- Endoscopic negative reflux disease (ENRD) = when a person has symptoms of GORD but normal endoscopy - Non-pharmacological management and medication review is as per other causes of dyspepsia
- May additionally benefit from sleeping with head of bed raised (e.g. raised on blocks)
-Specialist management may involve surgical methods, e.g. laparoscopic fundoplication
Pharmacological management of GORD
- PPI and H2RAs used
- Higher doses used than in uninvestigated dyspepsia to promote healing (see table below)
More severe symptoms / OGD results require more intensive treatment - Aim is to step down to lowest dose / PRN but some may need long-term maintenance PPI
Symptoms of Peptic Ulcer Disease
- Epigastric discomfort - Burning or gnawing (often well localised)
- Fullness / early satiety
- Bloating
- Nausea
- Heartburn
What are Peptic Ulcer Disease Complications
- Bleeding
- Perforation
- Obstruction
- Chronic iron deficiency anaemia
- Adenocarcinoma
Peptic Ulcer Disease - Treatment - Non-pharmacological and medication review advice per previous plus
- Stop NSAIDs
- Consider reducing or stopping (if possible and appropriate) any other potential ulcer-inducing drugs, e.g. aspirin, bisphosphonates, corticosteroids, crack cocaine
- Patients with inflammatory conditions may need to continue NSAID after ulcer healed – gastric protection and explain risks vs benefits
Causes and Risk factors of peptic ulcer disease
- Helicobacter pylori
- Medication esp NSAIDs, corticosteroids. Co-prescribed medicines may increase risk, e.g. anticoagulants
- Lifestyle especially alcohol intake, smoking, stress
- Genetic component
- Co-morbidities e.g. Crohn’s disease, Zollinger-Ellinger syndrome
Peptic Ulcer Disease - Treatment - Pharmacological management
- H. pylori test and treat
- Full dose PPI (e.g. lansoprazole 30mg OD, omeprazole 20mg OD) for 4-8 weeks (can offer H2RA if inadequate response)
- Follow-up 6-8 weeks after treatment – repeat endoscopy to confirm healing
- If healed, step down / stop treatment or use at lowest dose or PRN basis to control symptoms
