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Pharmacotherapy > Dyspepsia + GERD > Flashcards

Dyspepsia + GERD Flashcards

1
Q

Define dyspesia

A

epigastric pain lasting >/= 1 month

20% in population

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2
Q

Define GERD

A

Gastroesophageal reflux disease

  • troublesome, freq acid regurgitation or heartburn
  • incidence is 40% of the population
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3
Q

How is dyspepsia and GERD simlar?

A
  • considerable symptom overlap
  • difficult to differentiate based on pt history alone
  • many patients seek self-care options
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4
Q

Dyspepsia pathophys

  • what are some abnormalities that lead to it? (7)
  • what is it called with no abnormalities?
A
  • 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
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5
Q

GERD pathophys

4 possibilities

A
  • 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
  1. excess gastric acid production
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6
Q

Name 3 other risk factors for GERD

A
  1. drugs
    - Benzos, opioids, nicotine
  2. 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
  3. other: age>65, pregnancy, stress and anxiety
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7
Q

What are some complications that come with GERD? (6)

A

esophagus more vulnerable to damage with acid

  1. esophagus inflamm
  2. ulcers - hemorrhage
  3. strictures (narrowing)
  4. barrett esophagus/esophagus adenocarcinoma
    - Normal esophageal epithelium is replaced by intestinal-like epithelium
    - cells change shape and can become cancerous
  5. Aspiration pneumonia
    - reflux into lungs
  6. Gingivitis, halitosis, tooth decay
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8
Q

Symptoms of dyspepsia (6)

A
  1. Primarily epigastric pain
  2. Epigastric fullness /early satiety
  3. Bloating
  4. Nausea or vomiting
  5. Excessive belching
  6. Acid regurgitation
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9
Q

Symptoms of GERD (5)

A
  1. Primarily acid regurgitation, “heartburn”
  2. Nausea
  3. Dysphagia - difficulty swallowing
  4. Odynophagia - painful swallowing
  5. Miscellaneous symptoms: cough, sore throat, chest
    pain, hoarseness, SOB/wheezing
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10
Q

Red flags of dyspepsia and GERD

4+ others

A
  1. Abdominal mass / swelling
    - History of abdominal cancer
  2. Dysphagia, odynophagia, or choking
  3. Unintentional weight loss
  4. Symptom onset or worsening at >50 years of age
  5. What are some others…?
     Chest pain that resembles cardiac symptoms -Radiating
     GI bleeding - Coffee-ground vomitus or black, tarry stools
     Anemia - Dizzy, pale, fatigued
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11
Q

Goals of Therapy (5)

when can it be self-treated?

A
  1. Reduce or eliminate symptoms
  2. Reduce or prevent recurrences
  3. Induce healing of damaged mucosa
  4. Prevent complications
  5. Provide patient education
  • mild symptoms can be self-treated if less than 3 times a week
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12
Q

Non-pharm management
Dyspepsia (5)
what to avoid?

A
  1. lifestyle mod
    - avoid precipitating foods (alcohol, caffeine)
    - eat small freq meals
  2. avoid lying down right after meals (less than 3 hours)
  3. reduce body weight
  4. quit smoking
  5. 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

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13
Q

Non-pharm management

GERD (3 + dyspepsia)

A
  1. Avoid foods or drugs that may worsen or precipitate symptoms
  2. Avoid tight-fitting clothing
  3. Elevate head of bead about 10cm (foam incline or blocks)
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14
Q

Pharm management

what do people with dyspeptic symptoms need to do?

major treatment options (5)

A
  1. Antacids
  2. Histamine receptor antagonists (H2RAs)
  3. Proton-pump inhibitors (PPIs)
  4. 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
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15
Q

MOA of antacids?

what are some avaialbe pdts?
what is most potent?
least potent?

A
  • 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

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16
Q

How long do antacids act?

A
  • 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
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17
Q

AE for calcium carbonate?

A
  • 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
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18
Q

AE for sodium bicarbonate?

A

Caution for cardiac patients, high salt content

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19
Q

AE for magnesium?

A
  • Cause diarrhea
  • Avoided in renal failure
  • Limited in elderly because of risk developing hypermagnesemia
    (Nausea, vomiting, flushing, drowsiness, muscle weakness)
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20
Q

AE for aluminum salts?

A

Constipation

21
Q

Efficacy of antacids? (3 points)

A

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

22
Q

Antacids drug interactions

A
  • 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)

23
Q

Common OTC – Antacids

Tums

  • active ingredient
  • dose
  • SE
A
  • 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

24
Q

Common OTC – Antacids

Alka Seltzer, Eno

  • active ingredient
  • dose
A
  • 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
25
Q

Common OTC – Antacids

Diovol

  • active ingredient
  • dose
  • SE (1)
A

– aluminum / magnesium hydroxide

  • 30mL 1 hour pc and hs prn
  • SE: Combination product intended to offset constipation / diarrhea side effects
26
Q

Common OTC – Antacids

Milk of Magnesia

  • active ingredient
  • dose
  • SE (1)
A
  • magnesium hydroxide
  • Chew 2-4 tablets or drink 5-15mL up to QID prn
  • SE: diarrhea
27
Q

H2RAs

MOA?
good for what? trial length?

A
  • 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

28
Q

H2RAs

Efficacy (compare to PPIs and to themselves)

A
  • 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

29
Q

H2RAs

AE (3)
check for what? (2)

A
  • SE: headache, dizziness, constipation
  • Check for drug interactions
  • Adjust dose in renal impairment
30
Q

Common OTC – H2RAs

Zantac® (ranitidine)
- dose

A

 75mg or 150mg BID, or 300mg hs

- some recalled (type 1) due to high NMDA)

31
Q

Common OTC – H2RAs

Pepcid AC® (famotidine)
- dose

A
  • 10mg or 20mg BID
32
Q

Common OTC – H2RAs

Cimetidine (multiple brands)
- dose

A
  • 800mg – 1200mg daily in divided doses
33
Q

PPIs

good for what? trial length?
MOA?

A

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
34
Q

PPIs

Efficacy (compared to H2RAs)

A
  • 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
35
Q

PPIs
Drug / disease interactions

metabolized by which enzymes?

A
  • 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
36
Q

PPIs

AE (4)
long term safety concerns?

A
  • 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

37
Q

Common OTC – PPIs (2)

A

Nexium® – esomeprazole 40mg

Olex® – omeprazole 20mg

38
Q

Rx PPIs (ending)

A 
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®)
39
Q

Alginic Acid

brand?
dosage forms?
MOA?
Efficacy?
AE (1)
A

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
40
Q

Bismuth Subsalicylate

brand?
MOA?
Efficacy?
AE (2)

A

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+

41
Q

Monitoring
- when to refer?

F/U
- when to F/U

A
  • 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
42
Q

Pregnancy and Lactation

steps of recommendation?
breastfeeding issues?

A
  • 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

43
Q

Pediatrics

GER vs GERD?

A

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)
44
Q

Pediatrics

GERD symptoms

A
  • 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%)
45
Q

Pediatrics

GERD symptoms in adolescents and children

A 
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
46
Q

Pediatrics

Unique red flags

A 
 Bilious emesis: green like vomit due to presence of bile
 GI bleeding
 Failure to thrive
 Projectile emesis
 Fever
 Diarrhea or constipation
 Lethargy
 Bulging fontanelle
47
Q

Pediatrics

Non-pharm (2 main) for infants

A

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

48
Q

Pediatrics

Non-pharm (2 main) for children and adolescents

A 
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
49
Q

Pediatrics

pharm (3 main)

A
  • 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

Pharmacotherapy (14 decks)

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