Heartburn Flashcards by o e

What is the definition of eCare?

An interoperable standard for pharmacy providers to have a method of exchanging information
-> related to:
-patient goals
-health concerns
-active medication list,
-drug therapy problems
-laboratory results
-vitals
-payer information and billing services

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What is Interoperability?

Commonly agreed to a way of communicating data

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Reasons to use eCare?

-Lowering the number of miscommunications and medical errors (writing, speaking)
-assuring the message actually received by the physician

-follow up and monitoring
-prevention of chronic disease by optimizing medication use

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Goals of eCare

-informed decision-making at all levels of patient care
-focused on the pharmacist-physician documentation

-Medication Therapy Problem
-Patient Goals
-Interventions

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What are possible factors contributing to heartburn?

-Spicy food
-Alcohol
-eating shortly before going to bed
-NSAIDs
-Overweight
-No activity -> Exercise is preventative

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Function of the lower esophageal sphincter (LES)

-Permits passage of food into the stomach
-Contracted at rest
-Transient relaxation in healthy individuals
-The damage caused by gastric content is reduced due to mucosal resistance of the esophageal

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How is the content cleared from the esophagus?

Peristalsis, Saliva, gravity

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What alters the tightness of the LES?

-Age
-Medication
-Pressure (obesity, pregnancy)

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Clinical Presentation: Heartburn

-Pressure arising from the lower chest
-feeling that food is coming up
-belching

How often?
Mild: infrequent, episodic -> diet or lifestyle
Frequent: 2 days or more per week !!! EXAM

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What causes the relaxation of LES when not supposed to?
Pathophysiology

-Stimulation of sensory nerve endings in the esophagus
-> Spicy foods or reflux of gastric contents into the esophagus

-noxious quality of gastric contents: refluxed bile, gastric enzymes
-Esophageal tissue damage: due to bile, pepsin, gastric acid

-pressure
-impaired peristalsis (fe slowed gastric emptying (drug: GLP-1), saliva: reduced clearing of refluxed content from the esophagus

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Factors contributing to heartburn

-Diet
-Constipation
-Isometric exercises
-Lifestyle: No Exercising, smoking, anxiety, obesity
-Genetics, pregnancy

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Meds contributing to heartburn

-Aspirin/NSAIDs
-Vitamin C (high dose can aggravate acid reflux due acidity)
-Iron supplements
-many more…

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What is the frequency of symptoms in GERD?

Frequent and persistent: 2 or more days per week
-> Symptoms / Esophaegal damage

-should be REFERRED

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What are the typical symptoms of GERD?

-Heartburn, acid regurgitation (acid taste in
mouth), hypersalivation

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What are the alarming symptoms of GERD?

-Dysphagia (difficulty swallowing)
-odynophagia (pain when swallowing)
-chest pain
-upper GI bleeding
-unexplained
-weight loss
-nausea, vomiting, diarrhea

-> REFERRAL

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What are the diseases GERD can turn into?

-Erosive esophagitis
-Strictures (difficulties eating, swallowing)
-Bleeding
-Barrett’s esophagus
-Esophageal cancer

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Dyspepsia

Subjective feeling of discomfort primarily in the upper abdomen

-> associated with epigastric pain, burning, fullness after a meal, earl satiety

LESS commonly belching, bloating, nausea and vomiting

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Peptic ulcer disease (PUD)

-Gnawing or burning epigastric pain
-maybe together with heartburn and dyspepsia
-erosive (ätzend) component
-REFER -> longer treatment

during the day, and frequently at night

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Exclusion self-treatment heartburn

-heartburn for more than 3 months
-heartburn while on OTC PPI
-self-treatment for 2 weeks but still heartburn
-severe heartburn and dyspepsia
-Nocturnal (at night) heartburn
-Odynophagia/dysphagia (difficulty swallowing)

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More exclusions

-Coffee ground emesis (coughing of dark coagulated blood)/melena (black stool)
-Chronic hoarseness, wheezing, coughing, choking
-weight-loss
-N/V/D
-cardiac chest pain
-pregnancy, children

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Non-pharmacological therapy

-reduce fat intake, decrease portion size
-weight-loss
-elevating the head of the bed
-avoid food/drinks 3 hours before going to bed
-avoid irritating medication
-smoking cessation
-limit alcohol and caffeine

What are the pharmacologic therapies?

-Antacids (Bow and Arrow)
-Histamine2-Receptor Antagonists (H2RAs) (Rifle)
-Proton Pump Inhibitors (PPIs) (Rocket Launcher)
-Bismuth subsalicylate

Antacids

-short-term effect (but pt have to take it often, they get tired over time) -> 4x per day (MAX: 2 weeks)

-mild, infrequent heartburn/dyspepsia

API Antacids

-Sodium bicarbonate NaHCO3
-Calcium carbonate CaCO3
-Magnesium hydroxide MgOH2
-Aluminum hydroxide AlOH3
(Available alone and in combination)

Antacids MOA, Onset, Duration

-MOA: neutralizes acid in the stomach -Onset: 5 minutes (liquid faster than tablet) -Duration: 20-30 min (longer with food) Al and Ca are slightly longer than Mg and Bicarb -Minimal systemic absorption (<30%)

Adverse effects of Antacids

-Mg-containing: diarrhea (avoid: CrCl <30) -Al-containing: constipation -Ca-containing: belching, flatulence, constipation -Sodium bicarbonate: belching, flatulence, high sodium -caution in renal impairment (toxicity, renal calculi)

Drug Interactions

-increase or decrease absorption of other drugs -> Antimicrobials, iron (chelation process)

Histamine2-Receptor Antagonists

-Cimetidine (a lot of side effects) -Famotidine -Nizatidine -Ranitidine (FDA-recommended removal) - ingredient NMDA

What are Histamine2-Receptor Agonists used for?

-mild-to-moderate, infrequent, episodic heartburn and dyspepsia – Treatment of PUD (Rx only) -Usually once or twice daily for up to 2 weeks can develop tolerance

MOA, Duration, Onset of H2RA

-MOA: Inhibit H2 receptors on parietal cells to decrease gastric acid secretion and gastric volume -Onset: 30-60 min (longer on full stomach) -Duration: 4-10 hours -Dosing: every 12 hours or once a day

Adverse reactions of H2RA

-Rare - easy to tolerate -Headache, diarrhea, constipation, dizziness, drowsiness -Thrombocytopenia is rare

Drug interaction of H2RA

-Cimetidine potent inhibitor of CYP450 -Cimetidine associated with weak antiandrogenic effect

What are PPIs used for?

-frequent heartburn, PUD (Rx only) -Lansoprazole (Prevacid 24hr) 15 mg daily (max 2 weeks) -Omeprazole (Prilosec OTC) 20 mg daily (max 2 weeks) -Esomeprazole (Nexium 24hr)

When should patients take PPIs? EXAM!!!

30 minutes before the heaviest meal of the day -should be consistently at the same time of the day

MOA, Onset, Duration of PPIs

-MOA: Irreversibly inhibits proton pump (H+/K+ ATPase) -Onset: 2-3 hours -Duration: 12-24 hours Optimal benefit of effect: 1-4 days

Adverse effects

-RARE -Diarrhea -Constipation -Headache

What are the drug interactions of PPIs?

-Omeprazole: may decrease the effects of clopidogrel may increase the effects of Warfarin -Lansoprazole May decrease the effects of clopidogrel

Risks associated with PPIs

-depletion of nutrients: Ca, Mg, Iron, B12 (easy to replace with a single multivitamin) -> low Ca -> Fractures: risk for hip, spine, and wrist fractures in older patients (>50 years) -Infections: Cdiff and bacterial gastroenteritis; Community-acquired pneumonia -Rebound acid hypersecretion

How can Rebound acid hypersecretion be avoided?

-reduce high doses slowly before discontinuing the drug

What are the symptoms associated with PPI long-term use?

-Long-term: 4-5 years -Dementia -Chronic Kidney disease

Bismuth Subsalicylate MOA

MOA: unknown; Antisecretory effects may help relieve upset stomach

Indications of Bismuth Subsalicylate

-Nausea, diarrhea -heartburn -indigestion -upset stomach 262 – 525 mg every ½ to 1 hour PRN

Adverse effects of Bismuth Subsalicylate

-Contains salicylate (not for children under 12; or 16) -Caution in children with flu-like illness (Reye’s Syndrome) -May turn stool and tongue black -bleeding risk

What do look out for in patients taking Bismuth Subsalicylate?

-renal impairment -> Caution use antacids (contain Al, Mg), reduce daily dose of H2R -interacting medications -individualize medication choice to the patient

Heartburn medication in pregnant women?

-<12 -> REFER (but Antacids should be fine unless it is chronic) -Antacids with Mg and Al are safe -H2RAs are Category B -other products under physician supervision -Nursing mother (breast-feeding) - REFER

Drug to use -> Mild, infrequent heartburn and dyspepsia requiring immediate relief

Antacids, H2RAs no longer than 2 weeks

Mild-to-moderate, episodic heartburn requiring prolonged relief

H2RA no longer than 2 weeks

Mild-to-moderate: requiring both immediate and prolonged relief

Combination of Antacid and H2RA no longer than 2 weeks

Frequent heartburn or no response to H2RAs

PPI no longer than 2 weeks without provider supervision

What is the duration of frequent untreated heartburn that excludes patients from self-treatment?

3 months

Population of patients to exclude by age

<12 or older than 45

What are the risk factors for GI distress?

-60y or older -patients with a history of GI ulcers or bleeding problems -anticoagulants (warfarin), systemic steroids, NSAIDs -3 alcoholic beverages daily