Heartburn Flashcards
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
What is Interoperability?
Commonly agreed to a way of communicating data
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
Goals of eCare
-informed decision-making at all levels of patient care
-focused on the pharmacist-physician documentation
-Medication Therapy Problem
-Patient Goals
-Interventions
What are possible factors contributing to heartburn?
-Spicy food
-Alcohol
-eating shortly before going to bed
-NSAIDs
-Overweight
-No activity -> Exercise is preventative
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
How is the content cleared from the esophagus?
Peristalsis, Saliva, gravity
What alters the tightness of the LES?
-Age
-Medication
-Pressure (obesity, pregnancy)
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
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
Factors contributing to heartburn
-Diet
-Constipation
-Isometric exercises
-Lifestyle: No Exercising, smoking, anxiety, obesity
-Genetics, pregnancy
Meds contributing to heartburn
-Aspirin/NSAIDs
-Vitamin C (high dose can aggravate acid reflux due acidity)
-Iron supplements
-many more…
What is the frequency of symptoms in GERD?
Frequent and persistent: 2 or more days per week
-> Symptoms / Esophaegal damage
-should be REFERRED
What are the typical symptoms of GERD?
-Heartburn, acid regurgitation (acid taste in
mouth), hypersalivation
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
What are the diseases GERD can turn into?
-Erosive esophagitis
-Strictures (difficulties eating, swallowing)
-Bleeding
-Barrett’s esophagus
-Esophageal cancer
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
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
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)
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
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
