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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
H2RAs: SE
-HA -Dizziness and Fatigue -Constipation or Diarrhea -Somnolence + Confusion -Agitation -B 12 Deficiency
26
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**
27
PPIs
MOA: irreversible inhibition of H/K ATPase Onset: 2-3 hrs Duration: 24 hrs
28
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
29
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
30
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
31
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**
32
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
33
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
34
PPIs act as _ inhibitors
**Cyp2C19**
34
Strongest CYP2C19 inhibitors are
**Omeprazole and Esomeprazole**
34
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
35
TX overview of GERD
Lifestyle Modifications PRN Medications: Antacids H2RAs Scheduled Medications: H2RAs PPIs Surgery
36
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
37
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
38
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
39
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**
40
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
41
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
42
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

Therapeutics (63 decks)

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