Dyspepsia + GERD Flashcards
Define dyspesia
epigastric pain lasting >/= 1 month
20% in population
Define GERD
Gastroesophageal reflux disease
- troublesome, freq acid regurgitation or heartburn
- incidence is 40% of the population
How is dyspepsia and GERD simlar?
- considerable symptom overlap
- difficult to differentiate based on pt history alone
- many patients seek self-care options
Dyspepsia pathophys
- what are some abnormalities that lead to it? (7)
- what is it called with no abnormalities?
- Peptic ulcer disease (15-25%)
- Reflux esophagitis (5-15%)
- Gastric/esophageal cancer (<2%)
- Food intolerances (eg. Lactase deficiency)
- Medications/NHPs
- Infections
- other diseases (Celiac, Crohn’s)
- If no structural or biochemical abnormalities found, then referred to as functional, idiopathic, or non-ulcer
dyspepsia
GERD pathophys
4 possibilities
- mutlifactorial
possible:
1. Defective lower esophageal sphincter (LES): normally prevents backing up of gastric contents
2. Hiatal hernia: when stomach herniates above diaphragm, pressure on GI area
3. Impaired esophageal peristalsis / delayed gastric emptying: decreases clearance of acidic materal, increases volume and pressure in stomach causing reflux of gastric contents into esophagus
- excess gastric acid production
Name 3 other risk factors for GERD
- drugs
- Benzos, opioids, nicotine - lifestyle
- smoking, obesity, diet (weak associations but may worsen symptoms)
- Fatty foods delay gastric emptying
- Carbonated drinks cause distension and sphincter relaxation
- Chocolate, coffee, and alcohol may reduce sphincter tone - other: age>65, pregnancy, stress and anxiety
What are some complications that come with GERD? (6)
esophagus more vulnerable to damage with acid
- esophagus inflamm
- ulcers - hemorrhage
- strictures (narrowing)
- barrett esophagus/esophagus adenocarcinoma
- Normal esophageal epithelium is replaced by intestinal-like epithelium
- cells change shape and can become cancerous - Aspiration pneumonia
- reflux into lungs - Gingivitis, halitosis, tooth decay
Symptoms of dyspepsia (6)
- Primarily epigastric pain
- Epigastric fullness /early satiety
- Bloating
- Nausea or vomiting
- Excessive belching
- Acid regurgitation
Symptoms of GERD (5)
- Primarily acid regurgitation, “heartburn”
- Nausea
- Dysphagia - difficulty swallowing
- Odynophagia - painful swallowing
- Miscellaneous symptoms: cough, sore throat, chest
pain, hoarseness, SOB/wheezing
Red flags of dyspepsia and GERD
4+ others
- Abdominal mass / swelling
- History of abdominal cancer - Dysphagia, odynophagia, or choking
- Unintentional weight loss
- Symptom onset or worsening at >50 years of age
- What are some others…?
Chest pain that resembles cardiac symptoms -Radiating
GI bleeding - Coffee-ground vomitus or black, tarry stools
Anemia - Dizzy, pale, fatigued
Goals of Therapy (5)
when can it be self-treated?
- Reduce or eliminate symptoms
- Reduce or prevent recurrences
- Induce healing of damaged mucosa
- Prevent complications
- Provide patient education
- mild symptoms can be self-treated if less than 3 times a week
Non-pharm management
Dyspepsia (5)
what to avoid?
- lifestyle mod
- avoid precipitating foods (alcohol, caffeine)
- eat small freq meals - avoid lying down right after meals (less than 3 hours)
- reduce body weight
- quit smoking
- stress reduction
For GERD, avoid agents that impair esophageal motility and lower esophageal sphincter tone like anticholinergic agents, beta-adrenergic agonists, calcium channel blockers, theophylline and tricyclic antidepressants
Non-pharm management
GERD (3 + dyspepsia)
- Avoid foods or drugs that may worsen or precipitate symptoms
- Avoid tight-fitting clothing
- Elevate head of bead about 10cm (foam incline or blocks)
Pharm management
what do people with dyspeptic symptoms need to do?
major treatment options (5)
- Antacids
- Histamine receptor antagonists (H2RAs)
- Proton-pump inhibitors (PPIs)
- Other (Alginic acid, Bismuth subsalicylate)
Functional dyspepsia: recurring signs and symptoms of indigestion with no obvious cause
- Test for H. pylori which causes worse dyspepsia
- H. pylori - get ulcers
- Step process, start with antacids, move to H2RAs, move to PPIs
MOA of antacids?
what are some avaialbe pdts?
what is most potent?
least potent?
- Weak bases that neutralize existing stomach acid
- Raise gastric pH to prevent activation of pepsin
- pepsin digests proteins, which contributes to acid
- Produced in the chief cells of the stomach lining as one of the main digestive enzymes
- Suggested that pepsin causes the most damage when the reflux extends beyond the upper esophagus and reaches the pharynx
Available as:
Calcium carbonate (most potent)
Sodium bicarbonate (med potent)
Magnesium (med potent)
Salts of aluminum (least potent)
Some products contain a combination of salts
I.e. Magnesium combination is to offset the tendency of the respective (aluminum or calcium) agents to cause constipation - combo salts often used
How long do antacids act?
- Antacids only maintain an increased stomach pH only while they are in the stomach so the duration of the effect is dependent on the gastric emptying time
- After meal, 1-3 hours duration
AE for calcium carbonate?
- Constipation, belching, flatulence
- Milk alkali syndrome/Hypercalcemia when too much:
- More than 2-2.5g of calcium
- Nausea, weakness, altered mental status - immediate referral
- Use in malnourished or alcoholics: hypophosphatemia , muscle weakness, breathing , heart failure
AE for sodium bicarbonate?
Caution for cardiac patients, high salt content
AE for magnesium?
- Cause diarrhea
- Avoided in renal failure
- Limited in elderly because of risk developing hypermagnesemia
(Nausea, vomiting, flushing, drowsiness, muscle weakness)
AE for aluminum salts?
Constipation
Efficacy of antacids? (3 points)
little evidence in functional dyspepsia
- 20% in GERD for 1.5 hours
Related to ANC – acid neutralizing capacity (RxTx)
Doses are based on the ability of a product to neutralize a molar amount of acid. This is dependent on formulation.
In practice, just follow manufacturer guidelines!
not found in Canadian monographs or labelling
Inconvenient due to dosing frequency
Generally after meals and at bedtime (4-5 times a day)
Suspensions are preferred because have smaller particle
size which increases ANC
Antacids drug interactions
- Altered GI pH can affect the absorption of some medications
- Medications can adsorb to antacids, resulting in insoluble complexes
Clinically important examples:
Iron (prevents absorption)
Quinolones (e.g., ciprofloxacin; prevents absorption )
Sulfonylureas (diabetes medications whose absorption may be enhanced, leading to side effects)
Common OTC – Antacids
Tums
- active ingredient
- dose
- SE
- calcium carbonate
- 500-1500mg daily in divided doses (pc, hs)
- Preferred agent in renal failure
SE: constipation, kidney stones, acid rebound,
belching, milk-alkali syndrome
- Acid rebound: calcium carbonate can stimulate gastrin release leading to more acid reflux
Common OTC – Antacids
Alka Seltzer, Eno
- active ingredient
- dose
- sodium bicarbonate
- sachets or effervescent tablets
- occasional use only
- high salt content, avoid used in HTN, pregnancy, dysfunction because they may result in excessive fluid retention and edema
Common OTC – Antacids
Diovol
- active ingredient
- dose
- SE (1)
– aluminum / magnesium hydroxide
- 30mL 1 hour pc and hs prn
- SE: Combination product intended to offset constipation / diarrhea side effects
Common OTC – Antacids
Milk of Magnesia
- active ingredient
- dose
- SE (1)
- magnesium hydroxide
- Chew 2-4 tablets or drink 5-15mL up to QID prn
- SE: diarrhea
H2RAs
MOA?
good for what? trial length?
- Prevents movement of H+ ions into the stomach
- Reversibly bind to H2 receptors to inhibit proton pump action
- Inhibits basal acid secretion
Recommend 2 week trial for mild or moderate symptoms
rapid onset of action; used on-demand
PPIs are better for on demand symptoms
H2RAs
Efficacy (compare to PPIs and to themselves)
- Less potent than PPIs (suppress secretion by ~70%)
- All the H2RAs are considered to be equally effective and to have an excellent safety profile
- Effectively suppress nocturnal acid secretion
- Instructed to take 30 minutes before a meal or bedtime
Tachyphylaxis - tolerance to acid suppressing effect of this drug category (H2RAs), less effective over time
H2RAs
AE (3)
check for what? (2)
- SE: headache, dizziness, constipation
- Check for drug interactions
- Adjust dose in renal impairment
Common OTC – H2RAs
Zantac® (ranitidine)
- dose
75mg or 150mg BID, or 300mg hs
- some recalled (type 1) due to high NMDA)
Common OTC – H2RAs
Pepcid AC® (famotidine)
- dose
- 10mg or 20mg BID
Common OTC – H2RAs
Cimetidine (multiple brands)
- dose
- 800mg – 1200mg daily in divided doses
PPIs
good for what? trial length?
MOA?
Recommended for more than 2 times a week
Empiric treatment for 4-8 weeks
Best administered 30 minutes before a meal
MOA:
- acid-labile pro-drugs. When protonated, irreversibly bind and inhibit the proton pump.
- Optimal efficacy when proton pump activated.
- Formulation is coated to prevent acidic degradation (EC) dissolve in the intestine where it is rapidly absorbed
- Can take several days for full acid inhibition (2-5 days)
- short plasma half life, 24-48 hrs of acid suppression after new pump is inserted
PPIs
Efficacy (compared to H2RAs)
- May provide more rapid symptom relief than H2RAs
- More potent than other options for decreasing both basal and stimulated acid production (~80-95%)
- Help control both daytime and nocturnal symptoms
PPIs
Drug / disease interactions
metabolized by which enzymes?
- Mostly affect CYP 2C19, 3A4, 2D6
- Metabolized by CYP 2C19 and 3A4
- Dose adjustment may be required in liver disease for lansoprazole and esomeprazole
- Any meds dependent on low pH for absorption may have altered pharmacokinetics
PPIs
AE (4)
long term safety concerns?
- headache, nausea, diarrhea, rash
Long-term safety concerns
Vitamin B12 and iron deficiency
Pneumonia due to aspiration of stomach contents
Enteric infections (e.g., C. difficile)
Fractures
Rebound reflux upon discontinuation
Common OTC – PPIs (2)
Nexium® – esomeprazole 40mg
Olex® – omeprazole 20mg
Rx PPIs (ending)
Omeprazole 10 or 20mg (Losec®) Esomeprazole 40mg (Nexium®) Lansoprazole 15 or 30mg (Prevacid®) Dexlansoprazole 30 or 60mg (Dexilant®) Pantoprazole sodium 20 or 40mg (Pantoloc®) Pantoprazole magnesium 40mg (Tecta®) Rabeprazole 10 or 20mg (Pariet®)
Alginic Acid
brand? dosage forms? MOA? Efficacy? AE (1)
Gaviscon
- A combination product with alginic acid (sodium alginate, derived from seaweed) and aluminum hydroxide
- Liquid – 10-20mL pc and hs prn, followed by water
- Tablets – Chew 2-4 tablets pc and hs prn, followed by water
MOA: Forms a physical foamy layer on gastric contents, thereby decreasing exposure of the esophagus to acid
and bile
- Evidence for barrier effect is lacking
- May cause constipation
- SE related to antacid, not alginic acid
Bismuth Subsalicylate
brand?
MOA?
Efficacy?
AE (2)
Pepto Bismol
MOA: antimicrobial/anti-inflammatory
Efficacy / Safety
No appreciable acid-neutralizing capacity
May cause darkening of tongue and stool
From reaction between bismuth and sulfur
Tinnitus, rare neurotoxicity
Contraindicated in children or teenagers
Risk of Reye’s Syndrome, a swelling of the liver and brain
- calcium carbonate for children 2+
Monitoring
- when to refer?
F/U
- when to F/U
- If symptoms persist >2 weeks, worsen or develop into red flags, or occur multiple times a year, refer for further investigation
- have pt track triggers that exacerbate symptoms
- F/U 2-7 days
Pregnancy and Lactation
steps of recommendation?
breastfeeding issues?
- resolve post-partum, discuss with physician
- due to increased intra-abdominal pressure caused by growing fetus and reduced tone in lower esophageal sphincter that’s progesterone-mediated
- Recommend non-pharm measures first
- Antacids, alginates, H2RAs, and PPIs all considered safe butsome options may be more preferred.
Step 1: Calcium carbonate antacid of choice
Step 2: Ranitidine and cimetidine preferred over famotidine or
nizatidine because they have more fetal safety data
Step 3: Omeprazole preferred PPI
limited data in breastfeeding - likely fine
Pediatrics
GER vs GERD?
GER
- Passage of gastric contents into the esophagus
- Asymptomatic, causes no distress, no impact on growth
- Normal! (50% of infants less than 3 mos)
GERD
- troublesome for infant
- invasive testes (NG tubes, sedation)
- Trial of acid-suppression maybe be preferred in older children (>8yo)
Pediatrics
GERD symptoms
- Regurgitation/vomiting
- Feeding difficulties
- Arching post-feed (57%)
- Hematemesis
Extra intestinal symptoms:
Poor weight gain (28%)
Wheeze, persistent cough, stridor (40%)
Irritability/disturbed sleep/excess crying (70%)
Pediatrics
GERD symptoms in adolescents and children
GI symptoms: Heartburn Vomiting Regurgitation Feeding difficulties Dysphagia Chest pain Hematemesis
Extra intestinal: symptoms: Persistent cough Wheezing Stridor Laryngitis Chronic asthma Recurrent pneumonia Dental erosions
Pediatrics
Unique red flags
Bilious emesis: green like vomit due to presence of bile GI bleeding Failure to thrive Projectile emesis Fever Diarrhea or constipation Lethargy Bulging fontanelle
Pediatrics
Non-pharm (2 main) for infants
Parental education and reassurance
Infants:
Positional changes
Avoid laying flat immediately after feeds
Note that sitting/car-seat may actually increase GER
Elevation of head of bed 40°
Feed changes
Discuss with pediatrician
Pediatrics
Non-pharm (2 main) for children and adolescents
Similar measures as for adults Avoid fatty foods at dinner Based on adult studies: avoidance of caffeine, chocolate, spicy food Weight loss in obese patients
Pediatrics
pharm (3 main)
- antacids not used often
H2RAs
- famotidine, ranitidine
PPIs
- Usually 4-6 week trial for GERD, 3-6 months if erosive esophagitis
- Higher mg/kg dose than seen in adults because children have higher renal and hepatic function
Other
- more sever cases
