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GERD Flashcards

1
Q

Dyspepsia?

A

epigastric pain or discomfort originating from upper GI tract

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2
Q

GERD?

A

reflux of gastric content into esophagus –> very specific cause of dyspepsia

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3
Q

Term if no abnormalities found but have symptoms of dyspepsia?

A

functional dyspepsia

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4
Q

What are pts most commonly GI complaint categorized into?

A

uninvestigated dyspepsia

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5
Q

Potential mechanisms of functional dyspepsia?

A

gastric motility and compliance
visceral hypersensitivity
heliobacter pylori infection
altered gut microbiome
duodenal inflammation
psychosocial dysfunction; anxiety, depression, stress

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6
Q

When does functional dyspepsia treatment change (what cause)?

A

when heliobacter pylori infection

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7
Q

Risk factors for dyspepsia?

A

dietary indiscretion (over eating)
medications
H. pylori
anxiety
IBS
SMoking and alcohol use –> may not cause but worsen dyspepsia

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8
Q

Medications that can cause dyspepsia?

A

Bisphosphonates
Iron
NSAIDs
Potassium
TONS more but those are bolded ones

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9
Q

Main symptoms of dyspepsia?

A

epigastric pain or discomfort
fullness or early satiety
Nausea
upper abdominal bloating
excessive burping or belching
Heartburn and regurgitation –> more likely GERD (which is still dyspepsia but just a defnitive cause)

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10
Q

What is required to be considered dyspepsia?

A

greater than 1 month duration, relapse

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11
Q

Main alarming symptoms in regards to needing diagnositc work-ups?

A

vomitting
bleeding/anemia
abdominal mass or unexplained wt loss
dysphagia or odynophagia ( difficulty swallowing, painful swallowing)
Other important:
chest pain
choking

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12
Q

VBAD ?

A

vomitting
bleeding
abnormal mass
Dysphagia or odynophagia

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13
Q

What to do if any of the VBAD symptoms are present?

A

refer to doc for diagnostic assessments such as endoscopy

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14
Q

Dyspepsia vs GERD?

A

Dyspepsia is general umbrella term
GERD is a subset of dyspepsia main symptoms of heart burn and regurgitation

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15
Q

What is the main step in diagnosing dyspepsia?

A

eliminating other potential causes as the culprit

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16
Q

Steps of dyspepsia diagnosis?

A
  1. eliminate other potential causes as culprit
  2. upper GI location?
  3. New onset of symptoms? other than heartnurm and reflux, >50yrs, red flag symptoms?
  4. NSAID use?
  5. Reflux or regurgitation main symptoms?
  6. H. pylori present?
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17
Q

What % of canadians have some degree of dyspepsia?

A

30%

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18
Q

Age impacted the most for dyspepsia?

A

all ages impacted equally

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19
Q

GERD definition?

A

reflux of stomach acid contents into esophagus, possibly leading to reflux esophagitis or erosive esophagitis.

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20
Q

Causes of GERD?

A

defective lower esophageal sphincter
Increased intra-abdominal
Hiatal hernia
Impaired esophageal peristalsis
delayed gastric emptying
excessive gastric acid production?

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21
Q

reflux esophagitis or erosive esophagitis more common?

A

Reflux 70%
erosive 30%

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22
Q

Risk factors of GERD?

A

Obesity
Pregnancy
Family history
Smoking
Increased ag >65
Hiatal hernia
Stress and Anxiety
Medications
Diet (over eating mainly)

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23
Q

Drugs that induce GERD?

A

Anticholinergics*
Benzos*
Opioids***
alpha blockers
beta blockers
DHP-CCBs
Nicotine
Nitrates
THeophylline
Tetracycline

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24
Q

Dietary contributors to GERD?

A

OVER EATING**
fatty foods
chocolate
coffee
Alcohol
Carbonated Drinks
acidic juices
–> determine what food triggers it avoid it different for each pt

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25
Other potential SEs of GERD (not 2 primary ones)
belching hypersalvation Non-cardiac chest pain Chronic cough throat clearing SOB laryngitis dental erosions
26
Mild GERD classification?
Low intesity No daily interference < 3 week frequency < 6 months duration No nocturnal No complications
27
Moderate-Severe GERD classification?
High intensity interferes w/ daily life > 3 week frequency >6 month duration Nocturnal symptoms Complications present
28
How many moderate-high criteria does a pt need to be classified there?
1-2
29
2 Qs to ask to determine how severe a pts GERD is?
Nocturnal Sx? Daily interference?
30
Complications of GERD?
esophagitis esophageal stricture esophageal erosions barret's esophagus esophageal cancer
31
Red flags of GERD?
VBAD Choking Constant pain
32
Does the presence of GERD complications correlate to GERD symptoms?
not very well; can have bad complications and minimal symptoms and vice versa
33
How to accurately diagnose GERD?
hard to do, lots of tests, diagnosis on symptoms and ruling out other causes
34
Main drug class used to treat GERD?
PPI
35
Refractory GERD?
When pt has failed to control GERD on 4-8 week course of a PPI Sx recur within 3 months of PPI d/c
36
WHere is GERD more common?
western world asia <5%
37
Most common age for GERD?
>40
38
Goals of therapy for treating GERD?
relieve symptoms promote healing of injured mucosa*** prevent and treat complications prevent reoccurence avoid issues with long-term use of pharmacologics
39
Do pts need to be on long term treatment of PPIs?
no, 4-8 week course should cure GERD
40
Non pharm treatments of GERD?
lose and maintain ideal wt stop smoking elevate head of bed
41
As needed agents for GERD?
alginates antacids H2RAs PPIs
42
Fastest acting agents for GERD?
alginates antacids
43
Slowest acting agent for GERD?
PPI's
44
When to take alginates?
1 hour after eating
45
SEs of alginates?
bloating flatulence belching
46
alginate good agent?
meh not really
47
Antacids?
Aluminum hydroxide Magnesium hydroxide Magnesium trisillicate Calcium carbonate Sodium bicarbonate Can be combos of above
48
CI of antacids?
in severe renal impairment
49
What antacid used in dialysis?
Ca Carbonate and Aluminum hydroxide used as phosphate binder
50
MOA of antacids?
neutralizes stomach acid inhibits pepsin generation binds to bile acids
51
Onet and duration of antacids?
rapid acting short duration
52
When to take antacid?
20-30 minutes after eating
53
Common SEs of antacids?
aluminum: constipation Magnesium: laxative effect Ca: well tolerated, potentially constipation
54
Serious SE of antacids?
In chronic use not sporadic; Al: bone demineralization, neurotoxicity, hypophosphatemia Mg: hypermanesemia Ca: hypecalcemia, alkalosis
55
DI's of antacids b/c of chelation?
tetracycline fluroquinolones iron bisphosphonates digoxin phenytoin levothyroxine sotalol
56
How to avoid DI's with antacids?
1hr before meds or 2hrs after to avoid interaction To be on safe side --> (dig, levo,bisphosphonates) 4hr separation may be better to recommend
57
Does spacing of meds with PPI avoid DI's?
No b/c PPIs are long acting
58
DI's w/ antacids b/c of impaired absorption or pH sensitive drugs?
dabigitran HIV meds Fosinopril ketoconazole 5'-ASA products
59
Antacid efficacy?
better than placebo, good add-on b/c not better than other agents (PPIs and H2RA's)
60
H2RA drugs?
cimetidine famotidine ranitidine Nizatidine
61
Main off-label indication for H2RA's?
nocturnal GERD
62
Which H2RA is indicated for GERD maintanence of remission?
famotidine
63
MOA?
antagonist of H2 receptor which pump H+ into gastric lumen Reduction in basal and stimulated gastric acid secretion
64
Onset and duration?
1-3hrs onset 3-5 hr duration For nocturnal suppression lasts 8-13hrs
65
Are H2RA GERD dosing higher or lower than ulcer healing or H. pylori treatment?
GERD is lower
66
Common SEs of H2RAs?
Headache vomitting diarrhea drowsiness
67
Which H2RA is not well tolerated?
cimetidine b/c crosses BBB, gynecomastia also a SE of cimitidine
68
Why is cimetidine garbo in regards to DI's?
inhibits 1A2, 2C19, 2D6, and 3A4 phenytoin, clopidigrel, warfarin, metformin, cyclosporines, etc.
69
How to avoid H2RA itneractions in regards to decreased absorption / pH alteration (other than cimetidine)
4hr window to avoid interaction
70
H2RA efficacy?
more effective and potent than antacids very safe cheap significant tachyphylaxis (tolerance developed easily can happen on 8 weeks regular use) demonstrated*** great for step-down therapy
71
PPI drugs?
Rabeprazole omeprazole esomeprazole pantoprazole sodium/magnesium lansoprazole dexlansoprazole
72
Why did pantoprazole switch from Na to Mg?
theoretically gives longer duration of action to help with nocturnal GERD, clinically doesn't seem like it
73
Any PPI better than others?
All same efficacy, pt interindividual efficacy/ tolerance
74
Indications of PPI's?
GERD treatment healing of erosive esophagitis, duodenal and gastric ulcers prevention of NSAID induced ulcers H. pylori treatment zollinger ellison syndrome
75
MOA of PPI's?
inhbit proton pumps to prevent gastric acid secretion
76
Important factor of PPI to work?
atleast 30 min before meal, only works on actively proton pumps
77
Onset and duration of PPI's?
itial doses will result in suboptimal gastric acid inhibition daily use for atleast 3-5 days = maximal inhibiton Proton pump recovery takes 24-48hrs after d/c PPI
78
What dosing regiment should most pts be initiated on for PPI's?
standard dosing (once daily)
79
when is double-dose regimwent usedfor PPI's?
complciated presentation of GERD (mucosal errosion, ulcers or GI bleed, H. pylori, not effective standard dosing for 4-8 weeks)
80
when is hypersecretory dosing used for PPI's?
Zollinger-ellison syndrome
81
Is there renal dose adjustment with PPI's?
No, can be safely used in dialysis
82
Duration of therapy for PPI's?
4-8 weeks then d/c or step-down
83
Common SE's of PPI?
Very well toelrated dysgeusia (alterted taste bitter/metalic)
84
Potential Serious SE's with PPI's? (based on fairly weak evidence though) (very chronic used >5yr use)
CDIFF (most well established one) Microscopic colitis Hypmagnesemia Fractures Fundic gland polyps B12 defeciency Pneumonia Gastric Cancer Mortality increase; meh not really important
85
Which PPI's have enzyme interactions?
lansoprazole, omeprazole, esomaprazole
86
Can you space PPI's to avoid DI's due to absorption/pH?
No b/c PPI's long acting
87
Efficacy of PPI's?
most effecitve agent
88
Prokinetics drugs?
domperidone and Metoclopramide
89
Prokinetics use?
added for GI motility disorders, vague GI complaints
90
Dosing frequency of prokinetics?
TID or QID b/c short duration of action
91
CI of metoclopramide?
GI obstruction, perforation, hemorrhage Seizure disorder Parkinsons Extra-pyramidal symptoms (antipsychotic medication use; movement disorders) --> crosses BBB
92
CI of domperidone?
GI obstruction, perforation, or hemorrhage long QT interval (misleading, only at very high doses) electrolyte disorder use with potent 3A4 inhibtors
93
Which prokinetic is used more/ better?
domperidone b/c safer and cheaper
94
Metoclopramide SE's?
drowsiness muscle weakness headache dizziness confusion
95
Serious SEs w/ metoclopramide?
gynocomastia EPS syndrome pseudoparkinsons tardive dyskinesia hyperprolactinemia (worsen movement disorders more long term use)
96
SEs of domperidone?
dry mouth mild headache
97
Serious SE of dompeidone?
QT prolongation gynecomastia
98
DI's w/ metoclopramide?
2D^ inhibitors anti-parkinsons agents antipsychotics SSRIs and TCAs
99
DI's w/ domperidone?
3A4 substrate QT prolongation agents
100
Treatment approach of GERD (step-up)
lifestyle prn therapy shceduled H2RA schedule PPI
101
Treatment approach of GERD (step-down)
shceduled PPI lowest strength option to control symptoms
102
WHich treatment approach should be used for majority of pts?
step-down; PPIs very safe and effective
103
Monitoring for PPIs?
reassess sx at 4-8 weeks if resolved d/c if recur in >3 months after d/c begin anotehr 4-8 week course; if <3 months retreat but, investigate more If sx improved but still nt resolved continue for another 4-8 weeks
104
First step in refractory GERD treatment?
Failure cause; timing and adherence of med*** difference in PPI metabolism weakly acidic or alkaline reflux reflux hypersensitivity alternative diagnosis
105
Management of refractory GERD steps?
1. reassess for any VBAD sx 2. ensure adequate duration 3. ensure proper adherence and administration 4. reinforce lifestyle and dietary modifications 5. optimize or switch PPI 6. advanced daignostics 7. adjunct treatment addition (Algiante or antacid, prokinetics, H2RA hs, baclofen) 8. Surgery
106
Candidates to recommend deprescriping of PPIs?
mild-moderate GERD who responded to therapy peptic ulcer disease treated for proper duration asymptomatic for 3 consecutive days H. pylori eradication successful
107
How often should long-term PPI therapy be attempted to deprescribe?
once per year
108
Why taper PPI rather than d/c
to avoid rebound acid hypersensitivty/ GERD
109
Who does have a valid reason for chronic PPI use?
Barrets esophagus chronic NSAID (includes low dose ASA) w/ bleed risk severe esophagitis history of bleeding GI ulcer
110
Management of functional dyspepsia?
PPI once daily 4-8 weeks*** H. pylori testing*** switch / add TCA switch / add prokinetic
111
when is GERD treatment in infants to be considered?
poor wt gain blood in stool or vomitus intense irratability temporally realted to food intake
112
Treatment of GERD in infants?
usually just parent reassurence lifestyle trigger? trial of acid supression for 2 weeks (PPIs over H2RA's, need to be compounded b/c no liquid versions)
113
Saftey concerns for GERD treatment in infants?
acid rebound diarrhea pneumonia
114
What PPI is preferred in lactation?
pantoprazole
115
which antacids should be avoided in pregnancy?
Na bicarb Mg trisillicate
116
Drug induced esophagitis common drugs?
doxy/tetracycline K+ tabs ASA and NSAIDs bisphosphonates clindamycin
117
drug-induced esophagitis Risk increased by?
lying down after taking med swallowing pills w/ only saliva inadequate water intake esophageal dysmotility hiatus hernia esophageal stricture large pills bed ridden

PHAR 255 (14 decks)

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