GERD Flashcards
Gastroesophageal reflux
Retrograde movement of gastric contents from the stomach in to the esophagus
Gastroesophageal reflux disease (GERD)
A condition which develops when reflux of stomach contents causes troublesome symptoms and/or complications
Reflux esophagitis
Inflammation of the esophagus
Erosive esophagitis
Visible damage as seen on endoscopy
Epidemiology (4)
- Difficult to detect in infants and children
- Up to 35% of all children may have reflux within the first few months of life
- Reflux usually outgrown by 1 year of age
- Risk of reflux not subsiding increases with strong family history of GERD
Defense Mechanisms (5)
- Lower esophageal sphincter (LES)
- Esophageal mucus
- Esophageal clearance
- Acid neutralization, Via saliva
- Gastric emptying
Contributing Factors (6)
- Hiatal hernia
- Obesity
- Zollinger-Ellison Syndrome (Increased acidity due to gastrin production)
- Hypercalcemia
- Scleroderma
- Medications (Prednisone, CCBs, NSAIDs)
GERD Factors (5)
- Gastric Acid
- Pepsin
- Bile salts
- Pancreatic enzymes
- NSAID use
GERD risk factors (4)
- Decreased/increased LES pressure
- Delayed gastric emptying
- Increased gastric acid secretion
- Impaired gastro-esophageal pressure gradient
Treatment - Diet
Infant (1)
Children (3)
• Infant
Formula composition
• Children
Avoid foods that irritate GERD symptoms
Eat small meals
Avoid eating immediately prior to sleeping
Avoid exacerbating Meds
Treatment - Positioning Therapy
Infants (1)
Children (2)
Infants
Supine versus prone
Children
Elevate head of bed
Avoid reclining after meals
Pharmacological Treatments of GERD (4)
- Antacids
• Calcium carbonate
• Magnesium Hydroxide - Histamine 2 Receptor Antagonists
- Proton Pump Inhibitors
- Prokinetic Agents
Antacids MOA (2)
- Neutralize stomach acid
2. Deactivate pepsin and acidity of reflux
Antacids Place in therapy (2)
- Mild GERD
2. Immediate relief
Antacids (2) Available Agents
- Calcium Carbonate (Tums®, Maalox®)
2. Aluminum Hydroxide/Magnesium Hydroxide (Mylanta®)
Antacids ADE (4)
- Diarrhea (magnesium containing products)
- Constipation (aluminum containing products)
- Alteration in mineral metabolism
- Caution with acid rebound*
Antacids Drug Interactions (2)
- Fluoroquinolones
2. Tetracyclines
H2 Receptor Blockers MOA (2)
- Block histamine-mediated gastric acid secretion
2. Decrease acidity of reflux
H2 Receptor Blockers Available Agents (2)
- Ranitidine (Zantac®)
- TID dosing
- Large dosing range recommendation - Famotidine (Pepcid®)
- Twice daily dosing
- Standard dosing 1 mg/kg twice daily
H2 Receptor Blockers Place in Therapy (2)
- Mild to severe GERD
2. Also use for prevention
H2 Receptor Blockers ADE (6)
- Headache
- Mental confusion
- Somnolence
- Dizziness
- Abdominal discomfort
- Thrombocytopenia
H2 Receptor Blockers Pearls (2)
- Dose adjust with renal dysfunction
2. Tachyphylaxis – Increased risk with chronic use
Proton Pump Inhibitors MOA (3)
- Blocks acid secretion by inhibiting ATPase enzyme system in parietal cells
- Causes prolonged decrease in gastric acid secretion
- Decreases acidity of reflux
Proton Pump Inhibitors Available Agents(4)
- Esomeprazole (Nexium®)
- Omeprazole (Prilosec®)
- Lansoprazole (Prevacid®)
- Pantoprazole (Protonix®)
Proton Pump Inhibitors Place in Therapy (2)
- Used for more severe GERD symptoms
2. Erosive esophagitis
Proton Pump Inhibitors ADE (6)
- Diarrhea
- Flatulence
- Abdominal discomfort
- Dizziness
- Headache
- Infections
Omeprazole - Alternative Admin Technique/Pearls
Open capsules, mix with applesauce/Juice
Esomeprazole - Alternative Admin Technique/Pearls
Open capsules, dissolve in 60mL water for NG tube
Lansoprazole - Alternative Admin Technique/Pearls (2)
- Open capsules mix with applesauce, cottage cheese, pudding yogurt, strained pears, or 60mL tomato/orange/apple juice
- Liquid formulation is best option for enteral tube feeding
* If a child can’t take a capsule or has a G-tube or NG-tube, then lansoprazole should be go to agent
Pantoprazole - Alternative Admin Technique/Pearls (3)
- DO NOT CRUSH capsules
- delayed release packets (Do not use partial doses!)
- CYP drug-drug interactions
Prokinetic Agents MOA (2)
- Increase gastric emptying
2. Increase LES pressure
Prokinetic Agents Place in Therapy (2)
- Mild to moderate GERD
2. Severe GERD
Prokinetic Agents Available Agents (2)
- Metoclopramide (Reglan®)
2. Erythromycin
Prokinetic Agents ADE (6)
- Abdominal discomfort
- Acute dystonic reactions (Metoclopramide)
- Anxiety
- Insomnia
- Fatigue
- QT prolongation
Sucralfate (Carafate®) MOA
Forms a paste in the presence of gastric pH to coat the lining of the esophagus and stomach
Sucralfate (Carafate®) Place in Therapy (2)
- Used in combination with other therapies
2. Mild to moderate GERD
Sucralfate (Carafate®) ADE (4)
- Constipation
- Bezoar formation
- Abdominal discomfort
- Caution with administration with other medications