Heartburn and Dyspepsia Flashcards
Definitions - Symptoms
• Heartburn (“pyrosis”)
- Burning sensation of stomach or lower chest that rises up toward the neck and occasionally to the back
- Described as indigestion, acid regurgitation, sour stomach, or bitter belching
• Dyspepsia
- Symptoms originate from gastroduodenal region
- Bothersome postprandial fullness, early satiation, epigastric pain, and epigastric burning
• +/- anorexia, belching, NV, upper abdominal bloating
Disorders
• Gastroesophageal reflux disease (GERD)
- Sx: heartburn (common), dysphagia, odynophagia, globus sensation, hypersalivation, and regurgitation
• +/- esophageal damage resulting from reflux of acidic gastric contents into esophagus
- Peptic ulcer disease (PUD)
• Ulcers in the stomach/duodenum
• Dyspepsia can be a symptom
Dietary Risk Factors
- Alcohol
- Caffeinated beverages
- Carbonated beverages
- Chocolate
- Citrus fruits or juices
- Coffee
- Fatty foods
- Garlic or onions
- Mint (spearmint/peppermint)
- Spicy foods
- Sugars
- Tomatoes/tomato juice
Other Risk Factors
- Lifestyle • Emotions (anxiety, fear, worry) • Exercise (isometric, running) • Obesity • Smoking tobacco • Stress • Supine body position • Tight-fitting clothing
- Diseases
• Insulin resistance (pre-diabetes, diabetes, PCOS)
• Motility disorders (gastroparesis)
• PUD
• Scleroderma, Sjogren disease, Zollinger-Ellison syndrome - Pregnancy
- Genetics
Medications That May Cause Heartburn
Main • Aspirin/NSAIDs • Bisphosphonates • Iron • Potassium
Also • Alpha blockers • Benzodiazepines • Beta agonists • Calcium channel blockers • Opioid analgesics • Oral contraceptives • Doxycyline
Pathophysiology/Etiology of Dyspepsia
- PUD
- GERD
- Celiac disease
- Gastric or esophageal cancer
- Motility disorders
- Medications: NSAIDs, iron, antibiotics, opioids, digoxin, estrogens, theophylline
- Visceral hypersensitivity
Clinical Presentation: Heartburn
- Alone or as a symptom of GERD (2x/week is indicative) or PUD
- Within 1 hr of especially large meal or offending foods/beverages
- Lying down or bending over may exacerbate
- ≥2 times/week suggests GERD
- Regurgitation and water brash may also occur
- Generally classified as mild or moderate
- Mild - somewhat bothersome, doesn’t interfere with normal activities
- Moderate - bothersome sx that interfere with normal activities
Clinical Presentation: Dyspepsia
- Postprandial fullness
- Early satiation
- Epigastric pain
- Epigastric burning
- Less specific: • Bloating • Nausea • Belching • Vomiting
Alarm Symptoms
- Dysphagia
- Odynophagia
- Upper GI bleeding (hematemesis, melena, occult bleeding, anemia)
- Unexplained weight loss
Heartburn: Exclusions for Self-Treatment
- Frequent >3 months
- While on OTC H2RAs or PPIs
- Continuing after 2 weeks of OTC H2RA or PPI
- When taking RX H2RA or PPI
- Severe heartburn or dyspepsia
- Nocturnal heartburn
- Difficulty or pain swallowing solid foods
- Vomiting blood/black material or passing black tarry stools
- Chronic hoarseness, wheezing, coughing, or choking
- Unexplained weight loss
- Continuous N/V/D
- Chest pain + sweating, pain radiating to shoulder, arm, neck, or jaw, shortness of breath
- Children <2 y.o. [for antacids], <12 y.o. [for H2RAs], and <18 y.o. [for PPIs]
- Adults >45 y.o. with new-onset dyspepsia
Non-pharmacologic Therapy
- Diary to track dietary, lifestyle, and med triggers; then avoid those triggers
- Weight loss if overweight
- Elevate head of the bed 6-8 inches or use foam wedge (GERD pillow)
- Avoid tobacco products
- Dietary interventions
- Eat smaller meals
- Refrain from eating within 2-3 hours of lying down and sleep on left side
- Limit/discontinue alcohol or caffeine
- Plant-based Mediterranean diet and alkaline water (pH ≥8)
Pharmacologic Therapy
- Antacids
- Histamine type 2 receptor antagonists (H2RAs)
- Proton pump inhibitors (PPIs)
- Bismuth subsalicylate
Antacids: MoA
- Neutralize gastric acid; act as buffering agents in GI tract (pH >5, stop pepsinogen -> pepsin, increase LES pressure)
- FOR: Temporary and rapid relief of mild, infrequent heartburn
- Contain one of the following salts (all interchangeable):
• Magnesium (hydroxide, carbonate, or trisilicate)
• Aluminum (hydroxide or phosphate)
• Calcium carbonate
• Sodium bicarbonate
Antacids: Avoid If…
• Avoid antacid-aspirin combination products due to risk of serious bleed, especially in following patients:
- ≥60 years old
- History of stomach ulcers or bleeding problems
- Using anticoagulants, systemic steroids, or NSAIDs
- Consume ≥3 alcoholic beverages daily
Antacids: AEs,
- Mg2+ → diarrhea (avoid if CrCl <30 mL/min d/t toxicity)
- Al → constipation, hypophosphatemia (avoid if CrCl <30 mL/min)
- Ca2+ → belching and flatulence, constipation
• NaHCO3 → belching and flatulence
- Avoid in renal failure, HF, cirrhosis, pregnancy, and sodium-restricted diets
• If taking calcium supplement
- Avoid Ca2+ and NaHCO3 antacids
- Avoid Ca2+ antacid in renal failure
Antacids: Counseling
- Use product-specific doses, repeat in 1-2 hours if needed
- Food slows absorption (longer relief with food)
- Chew tablets well and drink 8 oz water
- Do not use >2x/week or >2 weeks
- May increase or decrease absorption other medications
- Separate by 1 hour: isoniazid
- Separate by 2 hours: Amphetamines, Azithromycin, Enteric-coated products, Iron, Itraconazole, ketoconazole
- Separate by 4 hours: tetracyclines and levothyroxine
- Take 2 hours before or 6 hrs after antacid: fluoroquinolones
H2RAs: MoA
•MoA
- Decrease fasting / food-stimulated gastric acid secretion and gastric volume by inhibiting histamine on the histamine type 2 receptor of the parietal cell
- Effective in relieving fasting and nocturnal symptoms
• FOR: mild-moderate, infrequent, or episodic heartburn and for prevention of heartburn associated with acid indigestion and dyspepsia
H2RAs: Info
- Not effected by food
• Relief not as rapid as antacids but duration is longer
• Lower dosages for mild, infrequent HB / higher dosages for moderate
• Reduce dose if impaired RENAL function (half dose in CrCl <50 mL/min) and in elderly
- Take at onset of sx or 30-60 min prior to anticipated heartburn, no more than 2x/day
- Tolerance may develop if taken daily (vs PRN)
H2RAs: Brands
- Tagament HB, Cimetidine 200 mg
- Pepcid AC/Zantac 360, Famotidine 10 mg
- Pepcid MAX, Zantac MAX, Famotidine 20 mg
^ ALL 1 tab with water, max 2 tabs
- Pepcid Complete/Tums: Famotidine + Ca carb + mag OH (chew 1 tab, max 2)
H2RAs: AEs, Interactions
• Adverse effects
- Headache, diarrhea, constipation, dizziness, drowsiness
- Thrombocytopenia is rare (and reversible)
- Cimetidine has weak anti-androgenic effects
• Drug interactions
- Cimetidine has many!!! Increases concentration of nifedipine (CCB) - monitor
- May decrease absorption of pH-dependent drugs: itraconazole, ketonazole, iron sulfate, calcium carbonate
PPIs: MoA
• MoA
- Inhibit H+/K+ ATPase (proton pump)
- Irreversibly block the final step in gastric secretion, thus providing a greater prolonged and potent effect
- Indicated for frequent heartburn with symptoms ≥2 days/week or when not responding to non-rx H2RAs
- Not intended for immediate relief or occasional and acute episodes of heartburn and dyspepsia
PPIs: Info
- Onset: 2-3 hours, may take 1-4 days for complete relief
- Do not chew or crush tablets/capsules
- Only inhibit proton pumps that actively secrete acid so most effective 30-60 min before meal (preferably before breakfast)
- Limit to 14 days of use, no more than every 4 months
PPIS: Brands
- Prilosec: Omeprazole
- Zegerid: Omeprazole + NaBiCarb
- Prevacid: Lansoprazole
- Nexium: Esomeprazole
^ ALL 1 tab max, 30 min before bfast
PPIs: AEs
- Uncommon but may include diarrhea, constipation, headache
- Rebound acid reflux upon abruptly discontinuing after long term use
- May increase risk of traveler’s diarrhea by altering glut flora
PPIs: Drug Interactions
• Omeprazole and esomeprazole
- May inhibit metabolism of clopidogrel via CYP 2C19 (check provider)
- May inhibit metabolism resulting in increased concentration of cilostazol and diazepam
• Avoid concurrent use
• Lansoprazole may be a safer alternative
Bismuth Subsalicylate (BSS)
- Indicated for heartburn, dyspepsia, indigestion, nausea, and diarrhea
- FDA approved for upset stomach (belching, gas) due to overindulgence in food and drink
- Topical effect on stomach mucosa
- Adult dose: 262-525 mg every 30-60 minutes as needed
- Not recommended for children or patients with renal failure or salicylate sensitivities
- May turn stool and/or tongue black
How to Select a Product
• Caution with elderly
- Avoid cimetidine; avoid H2RAs in those with or at high risk for delirium
• Caution with renally-impaired
- Avoid magnesium and aluminum antacids
- Avoid cimetidine; use low doses of other H2RAs
- Select antacid partly based on potential side effects
- Children >2 y.o. can use children’s formulas of calcium carbonate antacids
- Pregnancy
- Infrequent, mild heartburn: diet, lifestyle interventions
- Calcium and magnesium antacids ok (max 1000-1300 mg/day calcium)
- H2RAs are ok; PPIs likely ok but limited evidence (refer for moderate heartburn)
• Breast-feeding
- Aluminum, calcium, or magnesium antacids safe
- Famotidine>cimetidine
• Avoid PPIs
