Heartburn

Question 1

Define: Heartburn

Answer 1

occurs when stomach contents back up and out the stomach into the esophagus causing a burning sensation in the chest or throat

Question 2

Define: Dyspepsia

Answer 2

bad digestion that causes an uncomfortable feeling that is recurrent or consistent in the upper abdominal area

Question 3

What are risk factors for heartburn?

Answer 3

-> food and beverages= spicy/fatty foods, coffee, alcohol, carbonated/caffeinated beverages
-> lifestyle= overeating, eating <2 hours before bedtime, stress
-> medications= aspirin/NSAIDs, anticholinergic agents, chemotherapy, estrogen/progesterone
-> pregnancy
-> genetics
-> some disease states, such as gastroparesis (slowing of the GI tract) and peptic ulcer disease

Question 4

What is the SYMPTOM based criteria for exclusion for self-care for heartburn?

Answer 4

-frequent heartburn for > 3 months (2+ days a week)
-severe heartburn
-nocturnal heartburn
-vomiting blood or coffee ground appearance
-chronic hoarseness, wheezing, coughing, or choking
-unexpected weight loss
-continuous nausea, vomiting, diarrhea
-chest pain with sweating, shortness of breath, pain radiating to shoulder, arm, neck, or jaw
-difficulty or pain swallowing solid food
we want to ensure it is not cardiac in nature

Question 5

What age recommendations are there for self-care of heartburn?

Answer 5

do not treat heartburn OTC in children under 2 and adults over the age of 45 with new onset dyspepsia

Question 6

Define: Episodic/infrequent heartburn

Answer 6

1 or less times a month

Question 7

Mechanism of Action: Antacids

Answer 7

neutralize gastric acidity

Question 8

When is it appropriate to use antacids?

Answer 8

mild, infrequent heartburn or dyspepsia

Question 9

Onset of Relief: Antacids

Answer 9

<5 minutes

Question 10

Duration of Action: Antacids

Answer 10

20-30 minutes, duration is as long as the antacid is in the stomach

Question 11

Drug Interactions: Antacids

Answer 11

may bind with certain antibiotics, certain drug also need an acidic environment to be absorbed, may cause drug which are enteric-coated to be broken down early

Question 12

Mechanism of Action: H2RAs

Answer 12

inhibit histamine on the H2 receptor of the parietal cell, which decreases gastric acid secretion

Question 13

When is it appropriate to use H2RAs?

Answer 13

mild to moderate, infrequent or episodic heartburn and for the prevention of heartburn, requires renal dose adjustment

Question 14

Onset of Relief: H2RAs

Answer 14

30-45 minutes

Question 15

Duration of Action: H2RAs

Answer 15

4-10 hours, can be dosed 2x a day

Question 16

FAMOTIDINE

Answer 16

H2RA pepcid AC, Zantac 360, pepcid AC maximum strength. comes in 10 and 20 mg

Question 17

Drug Interactions: H2RAs

Answer 17

inhibits CYP450 which metabolizes lots of drugs, other H2RAs, and some drug need an acidic environment for absorption

Question 18

What are side effects of H2RAs?

Answer 18

headache, diarrhea, constipation, dizziness, drowsiness, possible thrombocytopenia(low blood platelet count)

Question 19

Pregnancy & Antacids?

Answer 19

category B- do not exceed recommended daily dose

Question 20

Patient Education Points: Antacids

Answer 20

-do not use more than 4x a day or regularly for 2 weeks
-calcium carbonate can be used in children under 2

Question 21

Patient Education Points: H2RAs

Answer 21

-tolerance can develop if taken daily, better to take as needed
-take 30 minutes-1 hour before symptoms or at symptom occurrence
-no more than 2x daily
-seek medical attention if used for more than 14 days
- >12 years old

Question 22

Pregnancy & H2RAs?

Answer 22

category B- compatible

Question 23

Mechanism of Action: PPIs

Answer 23

irreversibly inhibit the parietal cell H+/K+/ATPase enzyme system- blocking the first step of gastric secretion (bioavailability increases with continued doses)

Question 24

When is it appropriate to use PPIs?

Answer 24

for frequent heartburn in patients who have symptoms 2+ days a week- not intended for immediate relief of heartburn

Question 25

Onset of Relief: PPIs

Answer 25

2-3 hours, but complete relief could be 1-4 days

Question 26

Duration of Action: PPIs

Answer 26

12-24 hours

Question 27

What are the side effects of PPIs?

Answer 27

diarrhea, constipation, headache

Question 28

Drug Interactions: PPIs

Answer 28

reduces antiplatelet effect of clopidogrel and decreases absorption of antifungals, antiretrovirals, and iron supplements

Question 29

OMEPRAZOLE

Answer 29

PPIs Prilosec OTC, comes in 20mg

Question 30

Patient Education Points: PPIs

Answer 30

-do not crush or chew capsules
-take 30-60 minutes before a meal
-only take for 2 weeks
-can repeat in 4 months
- >18 years old

Question 31

Pregnancy & PPIs?

Answer 31

low risk

Question 32

Mechanism of Action: Alginic acid

Answer 32

reacts with sodium bicarbonate in saliva to form a viscous layer of sodium alginate that floats on the surface of gastric contents to form a protective barrier

Question 33

Mechanism of Action: bismuth subsalicylate

Answer 33

unclear for heartburn, but for upset stomach it acts via a topical effect on stomach mucosa

Question 34

Indication: bismuth subsalicylate

Answer 34

heartburn, upset stomach, indigestion, nausea, and diarrhea

Question 35

Patient Education Points: bismuth subsalicylate

Answer 35

may cause black stool or tounge

Question 36

What are nonpharmacologic recommendation for heartburn?

Answer 36

-elevate head of bed 6 inches or sleep with a foam wedge
-reduce size of meals
-avoid lying down for 3 hours
-avoid tight fitting clothes
-stop smoking
-weight loss
-avoid foods/medications that worsen symptoms