Ex 6. GERD/PUD (63) Flashcards
GERD
Symptoms or complications resulting from refluxed stomach contents into the esophagus or beyond, into the oral cavity (including the larynx) or lung”
GERD Epidemiology
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
Contributing factors of GERD
-Pregnancy
-Obesity
-Tobacco smoking
-Genetic Predisposition
-Alcohol Consumption
-Triggering Medications and foods (NSAIDs, coffee, spicy foods)
Pathophysiology of GERD
Abnormal Esophageal CL
-Mucosal resistance
-Lower LES pressure
-Acid pocket formation
-Gastric emptying + increased intra-abdominal pressure
Foods that worsen GERD
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
Clinical Presentation: Symptom based GERD
Heart Burn
-Regurgitation and Belching
-Reflux chest pain
Clinical Presentation of GERD: Esophageal
-Chronic cough
-Laryngitis
-Wheezing
-Asthma
Alarm Symptoms of GERD
-Dysphagia
-Odynophagia
-Bleeding
-Weight loss
Diagnosing GERD: Upper Endoscopy
-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
Diagnosing GERD: Ambulatory reflux +/- Impedance
-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
Diagnosing GERD: Manometry/High res esophageal pressure topography
-Barium Radiography
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
Complications w/GERD
-Erosive Esophagitis
-Stricture
-Barrett’s Esophagus
-Adenocarcinoma of the Esophagus
Goals of Care for GERD
-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
GERD Management
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
Lifestyle Modifications
Weight Loss
Sleep with head elevation
Avoiding late meals
Avoiding triggers
Portion Control
Exercise
Treat vs Referral
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
Antacids
Onset: 5 mins
Duration: 30-60 minutes
MOA: Neutralize gastric acidity
Antacids SE
Calcium
-Constipation
Magnesium
-Diarrhea
Aluminum
-Constipation
All can cause Nausea, vomiting and flatulence
Antacids: Drug interactions
Tetracyclines
Fluroquinolones
Levothyroxine
Digoxin
Azole antifungals
Steroids
Iron
HIV meds
Take meds 2 hours before or 6 hours after antacids
Antacids
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
Additional PRN Meds
Alka-Seltzer
-Sodium bicarbonate + aspirin + citric acid (has aspirin = not for children)
Pepto-Bismol
-Bismuth subsalicyclate (has aspirin = not for children)
Gas-X
-Simethicone
H2RAs
MOA
-Reversible inhibition of H2 receptor in parietal cells
Onset
60 minutes
Duration
4-6 hours
H2RAs: Famotidine (Pepcid, Zantac)
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
H2RAs: Cimetidine (Tagamet)
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
H2RAs: SE
-HA
-Dizziness and Fatigue
-Constipation or Diarrhea
-Somnolence + Confusion
-Agitation
-B 12 Deficiency
H2RAs Clinical Pearls
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
PPIs
MOA: irreversible inhibition of H/K ATPase
Onset: 2-3 hrs
Duration: 24 hrs
PPIs: Omeprazole (Prilosec)
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
PPIs: Pantoprazole (protoniz)
Dosing
PO: Rx: 20-40mg daily
IV rx: 40 mg daily
No renal dose adjustments
-Admin 60 minutes before first meal of the day
PPISL: Esomeprazole (Nexium)
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
PPIs: Lansoprazole (Prevacid)
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
PPIs: Dexlansoprazole (Dexilant)
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
PPIs: Side effects
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
PPIs act as _ inhibitors
Cyp2C19
Strongest CYP2C19 inhibitors are
Omeprazole and Esomeprazole
PPIS clinical pearls
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
TX overview of GERD
Lifestyle Modifications
PRN Medications: Antacids
H2RAs
Scheduled Medications:
H2RAs
PPIs
Surgery
Additional agents for GERD
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
Combination therapies: GERD
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
Surgical Management
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
Special Populations: Pregnancy
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
Special Populations: Lactation
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
Special Populations: Infants and children
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
Pediatric Treatment
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
