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Therapeutics > Ex 6. GERD/PUD (63) > Flashcards

Ex 6. GERD/PUD (63) Flashcards

1
Q

GERD

A

Symptoms or complications resulting from refluxed stomach contents into the esophagus or beyond, into the oral cavity (including the larynx) or lung”

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2
Q

GERD Epidemiology

A

Most common in patients aged 50 and older
~20% of adults in the U.S. Suffer from GERD symptoms
Prevalence of erosive esophagitis Barrett’s esophagus and esophageal adenocarcinoma higher in men

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3
Q

Contributing factors of GERD

A

-Pregnancy
-Obesity
-Tobacco smoking
-Genetic Predisposition
-Alcohol Consumption
-Triggering Medications and foods (NSAIDs, coffee, spicy foods)

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4
Q

Pathophysiology of GERD

A

Abnormal Esophageal CL
-Mucosal resistance
-Lower LES pressure
-Acid pocket formation
-Gastric emptying + increased intra-abdominal pressure

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5
Q

Foods that worsen GERD

A

Lower LES Pressure
-Fatty meal
-Peppermint and spearmint
-Chocolate
-Coffee, tea, sofa
-Garlic
-Onions
-Chili peppers
-Alcohol

Direct irritant
-Spicy foods
-Orange Juice
-Tomato Juice
-Coffee
-Tobacco

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6
Q

Clinical Presentation: Symptom based GERD

A

Heart Burn
-Regurgitation and Belching
-Reflux chest pain

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7
Q

Clinical Presentation of GERD: Esophageal

A

-Chronic cough
-Laryngitis
-Wheezing
-Asthma

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8
Q

Alarm Symptoms of GERD

A

-Dysphagia
-Odynophagia
-Bleeding
-Weight loss

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9
Q

Diagnosing GERD: Upper Endoscopy

A

-Preferred for assessing mucosal injury and complications

indicated for:
-Persistent or progressive GERD symptoms despite therapy
-Presence of alarm symptoms
-Screening for Barrett’s esophagus
-Placement of wireless pH monitoring
-Prior to endoscopic procedures or after procedures

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10
Q

Diagnosing GERD: Ambulatory reflux +/- Impedance

A

-Useful for patients not responding to acid suppression therapy when endoscopy is normal or have atypical/extraesophageal symptoms
-Assesses the acid exposure time (AET) and frequency of reflux episode s
-AET: <4% is normal, >6% is abnormal
-Reflux episodes is normal, >80 is abnormal
-Adding impedance measures both acid and nonacid reflux

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11
Q

Diagnosing GERD: Manometry/High res esophageal pressure topography
-Barium Radiography

A

Manometry:
-Useful in those who have failed twice-daily PPI therapy with normal endoscopic finding

Barium:
-Useful in detecting hiatial hernia
-Not routinely used to diagnose GERD because it lacks sensitivity and specificity

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12
Q

Complications w/GERD

A

-Erosive Esophagitis
-Stricture
-Barrett’s Esophagus
-Adenocarcinoma of the Esophagus

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13
Q

Goals of Care for GERD

A

-Alleviate/eliminate the patient’s symptoms
-Decrease the frequency or recurrence and duration of acid reflux
-Promote healing of the injured mucosa
-Prevent complications related to GERD

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14
Q

GERD Management

A

Prevention and treatment
-Lifestyle modifications

Neutralize Acid
-Therapies that target gastric acid (Antacids, H2RAs, PPI)

Reduce Gastric Acid Secretion
-Therapies that target H2 receptor and H/K ATPase

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15
Q

Lifestyle Modifications

A

Weight Loss
Sleep with head elevation
Avoiding late meals
Avoiding triggers
Portion Control
Exercise

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16
Q

Treat vs Referral

A

OTC/Patient Guided:
-No alarm symptoms
-Mild-moderate
-New onset
-Identifiable Triggers

Medical Referral
-Presence of alarm symptoms
-OTC trial for 14 days w/no relief

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17
Q

Antacids

A

Onset: 5 mins
Duration: 30-60 minutes
MOA: Neutralize gastric acidity

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18
Q

Antacids SE

A

Calcium
-Constipation
Magnesium
-Diarrhea
Aluminum
-Constipation

All can cause Nausea, vomiting and flatulence

19
Q

Antacids: Drug interactions

A

Tetracyclines
Fluroquinolones
Levothyroxine
Digoxin
Azole antifungals
Steroids
Iron
HIV meds

Take meds 2 hours before or 6 hours after antacids

20
Q

Antacids

A

Calcium Carbonate
-Tums

Magnesium Hydroxide
-Milk of Magnesia, Phillips

Aluminum + Magnesium
-Maalox,
-Gaviscon (+ alginate acid)

Aluminum Magnesium + Simethicone
-Mylanta Classic, Maalox advanced max strength

Calcium + Magnesium
-Rolaids
-Mylanta
-Supreme Ultra

Calcium + Simethicone
-Alka seltzer
Heartburn +Gas, Tums gas relief

21
Q

Additional PRN Meds

A

Alka-Seltzer
-Sodium bicarbonate + aspirin + citric acid (has aspirin = not for children)

Pepto-Bismol
-Bismuth subsalicyclate (has aspirin = not for children)

Gas-X
-Simethicone

22
Q

H2RAs

A

MOA
-Reversible inhibition of H2 receptor in parietal cells

Onset
60 minutes

Duration
4-6 hours

23
Q

H2RAs: Famotidine (Pepcid, Zantac)

A

Dosing
OTC: 10-20 mg BID (max: 40 mg/day)
Rx: 10mg BID PRN 10-60 minutes before meals
-If symptoms persist after 2-4 weeks may increase to 20 mg BID for 2 weeks. If symptoms improve, may continue therapy. If symptoms persist, may consider PPI

Renal adjustment
-CrCL <50mL/min: give 50% of dose

24
Q

H2RAs: Cimetidine (Tagamet)

A

Dosing:
OTC/Rx: 200mg daily up to 30 minutes BEFORE MEALS (max 400mg/day)
-Severe renal dose adjustment recommendations, only reduce in severe kidney impairment

Interactions
-Many drug-drug interactions via CYP1A2, 2C9, 2D6, and 3A4

25
Q

H2RAs: SE

A

-HA
-Dizziness and Fatigue
-Constipation or Diarrhea
-Somnolence + Confusion
-Agitation
-B 12 Deficiency

26
Q

H2RAs Clinical Pearls

A

Beer’s Criteria: Avoid use in patients at risk of delirium
-Used alone or in combination with other classes to treat mild-moderate GERD
-All H2RAs are equally efficacious

NOT AS EFFECTIVE AS PPIS

27
Q

PPIs

A

MOA: irreversible inhibition of H/K ATPase

Onset: 2-3 hrs
Duration: 24 hrs

28
Q

PPIs: Omeprazole (Prilosec)

A

Dosing
-OTC: 20 mg once daily * 14 days, may repeat in 4 months
Rx: 10-40 mg once daily
-No renal dose adjustments
-Administer 30-60 minutes before first meal of the day

-metabolized by CYP2C19

29
Q

PPIs: Pantoprazole (protoniz)

A

Dosing
PO: Rx: 20-40mg daily
IV rx: 40 mg daily

No renal dose adjustments
-Admin 60 minutes before first meal of the day

30
Q

PPISL: Esomeprazole (Nexium)

A

Dosing
OTC: 20 mg once daily x 14 days may repeat in 4 months

POrx: 20-40mg once daily
IV Rx: 20-40mg once daily

No renal dose adjustments
Admin 30-60 minutes before first meal of the day

Metabolized by CYP2C19

31
Q

PPIs: Lansoprazole (Prevacid)

A

Dosing
OTC: 15 mg once daily x 14 days, may erpeat in 4 months
Rx: 15-30 mg daily

No renal dose adjustments
Orally disintegrating tablet available

Admin 30-60 minutes before first meal of the day

32
Q

PPIs: Dexlansoprazole (Dexilant)

A

Dosing: Rx only

No complications present: 30 mg daily

Complications present: 60mg daily x 8 weeks, then 30mg indefinitely

No renal dose adjustments

Dual release formulation (onset 1-2 hours and again at 4-5 hours)

Can be taken w/o regard to meals

33
Q

PPIs: Side effects

A

Short Term:

HA, Dizziness
Diarrhea, flatulence
Nausea, abdominal pain
Enteric infections, community acquired pneumonia - increase risk of Cdiff

Long-Term:

Hypomagnesemia
Bone Density Decrease/Fractures
Vitamin B12 deficiency
Chronic Kidney Disease

34
Q

PPIs act as _ inhibitors

A

Cyp2C19

34
Q

Strongest CYP2C19 inhibitors are

A

Omeprazole and Esomeprazole

34
Q

PPIS clinical pearls

A

Initial Tx duration should last no more than 8 weeks on Rx PPI and 14 days on OTC PPI

Maximize therapy by increasing dose, frequency or switching PPIs

Beer’s Criteria

Recommended taper after long-term therapy

35
Q

TX overview of GERD

A

Lifestyle Modifications

PRN Medications: Antacids
H2RAs

Scheduled Medications:
H2RAs
PPIs

Surgery

36
Q

Additional agents for GERD

A

Promotility agents (Metoclopramide, Bethanechol)
-May be useful as adjunct therapy if there is a known motility defect
-These agents are NOT as effective as acid suppression therapy and have undesirable side effects

Mucosal protectant (Sucralfate)
-Limited use in tx of GERD but may be useful for management of radiation esophagitis and non acid reflux GERD

37
Q

Combination therapies: GERD

A

Antacids + H2RAs
-May be helpful for heartburn after meals
-Pepcid AC: Famotidine + Calcium Carbonate and Magnesium

PPIs + H2RAs
-Nighttime dose of H2RA can help with overnight acid production
-H2RAs can provide breakthrough relief in patients on PPI

38
Q

Surgical Management

A

Antireflux surgery
-Consider when long-term pharmacotherpay is undesirable or when patients have complications
-Reinforces the lower esophageal sphincter
-Reduces regurgitation and acid back-flow

39
Q

Special Populations: Pregnancy

A

1st Line: Antacids that do not contain aspirin
2nd line: H2RAs
Last line: PPis which should be reserved for severe or refractory cases

Recommend lifestyle modifications prior to pharmacologic options

40
Q

Special Populations: Lactation

A

Antacids
-Data is lacking, considered generally acceptable

H2RAs
-Excreted in breast milk at low amounts

PPIs
-Excretion into breast milk is minimal
-Most data on pantoprazole and omeprazole

41
Q

Special Populations: Infants and children

A

Symptoms of GERD
-Refusing to eat
-Wheezing/coughing
-Dental erosion
-Recurrent regurgitation
-Irritability

Monitor for Alarm Symptoms
-Weight loss
-Fever
-Seizure
-Persistent vomiting and diarrhea

Non-Pharm Options*
-Thickening formula/food
-Decreasing volume of intake
-Milk free diet
-Positioning therapy

42
Q

Pediatric Treatment

A

PPIs and H2RAs
-Treat for 4-8 weeks
-Only for diagnosed GERD or esophagitis

Antacids
-Should not be used chronically
-Do not use aluminum or bismuth subsalicylate containing antacids in children <12 years

Simethicone
-Safe and OTC

Probiotics
-Safe and OTC

Herbal Options
-Ginger (ginger ale), chamomile or peppermint

Therapeutics (61 decks)

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