Dyspepsia Flashcards
What is dyspepsia?
Predominant epigastric pain for at least 1 month
Difference between organic and functional dyspepsia
- Organic = peptic ulcer disease, GERD, cancer
- Functional = non-ulcer
Difference between PUD and GERD
- Peptic ulcer disease sx = episodic epigastric pain and heartburn
- GERD -> considered a chronic disease or chronically relapsing disorder; sx:
- Classical = regurgitation, heartburn, dysphagia, odynophagia (pain on swallowing)
- Atypical = coughing, wheezing, globus sensation, chest pain
Potential causes of PUD and GERD
- Peptic ulcer disease -> H. pylori, NSAIDs, smoking, EtOH, caffeine
- GERD -> pregnancy, obesity, increased age, histus hernia
What is considered PUD recurrence
- Failure of 8-week therapy in duodenal ulcer
- Failure of 12-week therapy in gastric ulcer
- *Always look for a reason (non-adherence, H. pylori, NSAIDs)
Functional dyspepsia tx
- Functional dyspepsia: dyspepsia of at least 3 months w/ no clearly identifiable pathology
1. Test and treat for H pylori
2. Pt is H pylori negative -> endoscopy, PPI, prokinetics, CBT and other psychological approaches
3. If pt tries PPI and has no sx relief -> consider TCA (amitriptyline, imipramine) over prokinetics - 4 weeks is an adequate trial period
Use of antacids for dyspepsia
- Peptic ulcer disease and GERD -> used for sx relief
- Take at 1 and 3 hours post-meal and at HS
- Can be used PRN for GERD
- AE = constipation/diarrhea, drug interactions
- *Important -> don’t use sodium bicarb products in CHF/cirrhosis px and don’t use magnesium products chronically in dialysis px (use aluminum or calcium instead)
- Functional dyspepsia -> limited to no benefit
Use of H2 receptor blockers for dyspepsia
- All agents the same at appropriate dosage
- All can be given 1 or 2x/day
- GERD -> can be up to 2x the PUD dose (ex: ranitidine 300 mg BID) but rarely done b/c PPIs cost around the same
- AE = very low; drug interactions w/ cimetidine, so recommend ranitidine
Use of PPIs for dyspepsia
- Gold standard for PUD and GERD
- Functional dyspepsia -> only small benefit; more beneficial for ulcer & reflux-like sx; limit to once daily
- Effects last 3 days
- Increasing omeprazole dose from 20 mg to 40 mg only decreases acid by further 6%
- AE = nausea, headache, dizziness, diarrhea, sweating
- Take 30 mins before morning meal or evening meal if primarily nocturnal sx
- *Don’t continue long-term unless attempt to stop/reduce tx at least once/year except if Barrett’s or GI bleed
Drug interactions w/ PPIs
- Any drugs w/ low pH dependent absorption
- May increase MTX, digoxin, and tacrolimus levels
- Omeprazole and esomeprazole may decrease clopidogrel’s conversion to active drug; may consider switching to pantoprazole
Red flags for dyspepsia
- Alarm features = VBAD (warrants prompt endoscopy)
- Vomiting > 7 days
- Bleeding
- Abdominal mass or unexplained weight loss (ex: 10% body weight)
- Dysphagia
- Others = jaundice, family hx of gastric cancer, prior ulcer
- Refractory GERD
Case specific assessment questions for dyspepsia
- Do you regularly use NSAIDs?
- Is the predominant sx heartburn and/or regurgitation? (if yes, indicates GERD)
- Have you been tested for H. pylori?
Non-pharms for dyspepsia (general)
- Peptic ulcer disease -> avoid large meals right before bed (increases HS acid production); avoid precipitants (NSAIDs, ASA, smoking, EtOH > 20% proof, excess caffeine)
- GERD and functional dyspepsia -> smaller, more frequent meals; avoid precipitants (certain foods, smoking, alcohol, caffeine); stress reduction; smoking cessation, exercise and weight loss
General monitoring for dyspepsia
- For FD px, 4 weeks is plenty of time to determine if a drug is working or not
- Pt monitor symptoms daily
General follow up for dyspepsia
- Pharmacist follow up in 1 week to see if sx improving
- Reassess GERD therapy in 4 weeks -> if sx improve, stop therapy; if sx don’t improve w/ PPI, increase to BID for 4-8 weeks then reassess
Describe monitoring for PUD
- Monitor for sx improvement and side effects from the drug daily/weekly
- Common SE of PPI = N, headache, dizziness, diarrhea, constipation
Describe when to go to a Dr for PUD
Go to doctor if sx haven’t improved after using PPI for 8 weeks in duodenal ulcer, or after using PPI for 12 weeks in gastric ulcer
Describe when to go to emergency for PUD
Go to emergency if vomiting for > 7 days, jet black stools/bleeding (melena), abdominal mass of unexplained weight loss (10% body weight), dysphagia (VBAD)
Describe non pharms for PUD
- Avoid large meals before bed
- Try to remain upright for a few hours after eating
- Avoid caffeine, spicy foods, chocolate, etc. (trigger foods)
- Avoid NSAIDs if possible
- Exercise and weight loss
- Smoking cessation and moderate alcohol intake
Describe follow up for PUD
I will follow up with you 1 week to discuss sx improvement, adherence, and SE management
Describe monitoring for GERD
- Monitor for sx improvement and SE of medication daily
- Mild sx (< 3x/week, short duration, low intensity) can often be managed w/ lifestyle and dietary changes
- Typical sx = heartburn and/or acid regurgitation
- Common SE of PPI = N, headache, dizziness, diarrhea, constipation
Describe when to go to a Dr for GERD
Go to doctor if refractory GERD, trial of PPI for 4-8 weeks
Describe when to go to emergency for GERD
Go to emergency if vomiting for > 7 days, jet black stools/bleeding (melena), abdominal mass of unexplained weight loss (10% body weight), dysphagia (VBAD)
Describe non pharms for GERD
- Avoid large meals before bed
- Try to remain upright for a few hours after eating
- Avoid caffeine, spicy foods, chocolate, etc. (trigger foods)
- Avoid NSAIDs if possible
- Exercise and weight loss
- Smoking cessation and moderate alcohol intake
- *List of drugs that cause can GERD on bottom of pg. 67 RxFiles
Describe follow up for GERD
I will follow up with you 1 week to discuss sx improvement, adherence, and SE management
Describe monitoring for functional dyspepsia
- Monitor for sx improvement daily/weekly
- Common SE of PPI = N, headache, dizziness, diarrhea, constipation
Describe when to go to a Dr for functional dyspepsia
Go to doctor if no sx relief after 4-week trial of PPI
Describe when to go to emergency for functional dyspepsia
Go to emergency if vomiting for > 7 days, jet black stools/bleeding (melena), abdominal mass of unexplained weight loss (10% body weight), dysphagia (VBAD)
Describe non pharms for functional dyspepsia
- Avoid large meals before bed
- Try to remain upright for a few hours after eating
- Avoid caffeine, spicy foods, chocolate, etc. (trigger foods)
- Avoid NSAIDs if possible
- Exercise and weight loss
- Smoking cessation and moderate alcohol intake
Describe follow up for functional dyspepsia
- I will follow up with you 1 week to discuss sx improvement, adherence, and SE management
- After 4 weeks we will reassess if you should stay on the drug or stop it and try something else
Describe monitoring for a new PPI Rx
- Monitor for sx improvement and side effects daily/weekly
- Common SE of PPI = N, headache, dizziness, diarrhea, constipation
Describe when to go to a Dr for a new PPI Rx
Go to doctor if no sx improvement after 4-8 week trial of PPI; next step = 4-8 week trial of BID PPI
Describe when to go to emergency for a new PPI Rx
Go to emergency if vomiting for > 7 days, jet black stools/bleeding (melena), abdominal mass of unexplained weight loss (10% body weight), dysphagia (VBAD)
Describe non pharms for a new PPI Rx
- Avoid large meals before bed
- Try to remain upright for a few hours after eating
- Avoid caffeine, spicy foods, chocolate, etc. (trigger foods)
- Avoid NSAIDs if possible
- Exercise and weight loss
- Smoking cessation and moderate alcohol intake
Describe follow up for a new PPI Rx
- I will follow up with you 1 week to discuss sx improvement, adherence, and SE management.
- We will reassess your sx at 4 weeks and decide if we should continue or stop the drug
Describe monitoring for a new H. pylori infection
- Monitor for sx improvement daily and SE
- Common SE of PPI = N, headache, dizziness, diarrhea, constipation
- Common SE of antibiotics = GI upset
Describe when to go to a Dr for a new H. pylori infection
Go to doctor if no sx improvement after full course completed or if minimal sx improvement 7 days after antibiotic course completed
Describe when to go to emergency for a new H. pylori infection
- Go to emergency if vomiting for > 7 days, jet black stools/bleeding (melena), abdominal mass of unexplained weight loss (10% body weight), dysphagia (VBAD)
- If sx worsen as any point
Describe non pharms for a new H. pylori infection
- Avoid large meals before bed
- Try to remain upright for a few hours after eating
- Avoid caffeine, spicy foods, chocolate, etc. (trigger foods)
- Avoid NSAIDs if possible
Describe follow up for a new H. pylori infection
- I will follow up with you 3 days to discuss adherence to the complicated regimen and to see if sx have improved
- I will also follow up at 14 days when the regimen should be completed to see how your sx are doing
