Heartburn and Dyspepsia Flashcards
What is heartburn
-burning in the stomach or lower chest; may extend up toward neck and occasionally the back
-usually occurs within 1 hour after eating; often after a large meal
-may be referred to as indigestion, acid indigestion, sour stomach
What is GERD
-frequent reverse flow of stomach acid and contents into the esophagus
*chronic condition
**NOT for pharmacists to recommend therapy
-characterized as heartburn 2 or more times a week
What is dyspepsia
-early fullness, epigastric pain/burning
-symptoms originate from gastroduodenal region
-can cause anorexia, belching, nausea, vomiting, upper abdominal bloating, heartburn, regurgitation
for those experiencing heart burn and dyspepsia, who should not self-treat?
-dysphagia(difficulty swallowing)
-odynophagia(painful swallowing)
-vomiting
-GI bleeding
-unexplained weight loss
-noncardiac chest pain
-asthma
-voice changes
-feeling of “lump in the throat”
-chronic cough
-trouble sleeping
-dental erosion
What are some non-pharmacologic options someone might try to help with their heartburn or dyspepsia
-acupuncture for symptoms
-weight loss
-no food within 2-3 hours of bedtime
-sleep on left side (relieves pressure on LES)
-elevate head of bed with 6-8 in blocks underneath legs or foam GERD pillow
-stop tobacco use
-limit or stop alcohol intake
-mediterranean diet
-symptom diary
-assess rx and OTC meds
-modify lifestyle
What might you consider when recommending a OTC treatment option for heartburn/dyspepsia
-frequency, duration and severity of symptoms
-medication cost
-drug-drug interactions
-adverse effects
-patient preference
What are the classes of medications available for heartburn/dyspepsia?
- Antacids
- H2RAs
- PPI
- Bismuth subsalicylate
What medication could someone take if they are experiencing mild-mod, infrequent heartburn or dyspepsia and they only need short-term relief?
Antacid
-rapid relief
-interchangeable at recommended doses
-antacid/alginic acid more effective in combo
H2RA
-slower relief
What would you recommend someone experiencing mild-mod infrequent HB or dyspepsia but need longer-lasting relief
H2RA
-slower relief
-can use with antacid
-can use to prevent HB if taken 3-60 minutes prior to know cause of symptoms
-lower dose for mild symptoms
higher dose for mod symptoms
What would you recommend a patient take if they are experiencing heart burn 2 or more fays a week
PPI and/or H2RA
-take the PPI daily for 14 days ONLY
-take H2RA as needed
What is the onset of relief and duration of relief for antacids?
onset within 5 minute
*if liquid, no time delay
lasts for 20-30 minutes on empty stomach
lasts for up to 3 hours if there is food in the stomach
What is the duration and onset of relief of H2RAs
onset of relief in 30-45 minutes
duration is 4-8 hours for cimetidine and 4-10 hours for famotidine
What is the duration and onset of relief of H2RAs and antacid combine together
onset of relief is within 5 minutes and duration is 8-10 hours
What is the duration and onset of relief of PPIs
onset of relief occurs within 1-3 hours of taking but may need 1-4 days for full effect
duration is 12-24 hours for a single dose
What should you recommend someone if the initial therapy of antacid or alginic acid/antacid combo or H2RA/antacid combo not helpful
try a different agent
OR
medical referral
If HB occurs 2 or more days per week and taking a PPI once a day for 14 days or H2RA is needed
-refer if not better after 2 weeks
-if better, continue with lifestyle/diet changes, stop PPI
*may repeat PPI every 4 months if needed or continue H2RA as needed
What is the MOA of antacids
neutralize the gastric acid and increase LES pressure
aliginic acid + sodium bicard in saliva = layer of sodium alginate on top of stomach contents(= protective barrier)
What is the indication of antacids?
Treatment of mild, infrequent heartburn, sour stomach, and acid indigestion
Rank the formulations of antacids from fastest to slowest: liquid, chewable, quick-dissolving
Liquid formulation > quick-dissolving tablets > chewable tablets
What is the duration of antacid on an empty stomach?
lasts for 20-30 minutes on an empty stomach
lasts 2-3 hours when food is in stomach
What is the dosing for antacids
-take dose at symptom onset
-repeat dose in 1-2 hours if needed
*there are product-recommended dosing and they should not exceed
When should you reevaluate antacid use
-using more than twice a week
-using regularly for more than 2 weeks
What are some side effects that can occur when taking antacids
-aluminum: cause constipation(can be managed when used in combo with magnesium), hypophosphatemia
-calcium carbonate: belching, intestinal gas, constipation; hypercalcemia can occur is kidney dysfunction
-magnesium: diarrhea(manage by taking with aluminum)
-sodium bicarb: belching, intestinal gas
When should antacids be avoided?
-dyspepsia
-aluminum or calcium should be avoided if there is kidney dysfunction
-magnesium if creatine clearance is less than 30mL/min
-Sodium bicarb should be avoided in those with: sodium restriction, heart failure, kidney failure, cirrhosis, pregnancy, taking calcium supplements, concomitant aspirin therapy
What are the 2 HR2A products on the market
cimetidine and famotidine
What is the MOA of HR2A
reduce acid secretion by inhibiting histamine at the H2 receptors on parietal cells in the lining of the stomach
What is the indication for cimetidine and famotidine
-for mild to moderate, infrequent or episodic HB or prevention of HB
Can you combine HR2A with antacids
Yes, you can combine if not already pre-medicated with HR2A
What is the duration for famotidine
4-10 hours
What is the duration of cimetidine
4-8 hours
What is the onset for cimetidine and famotidine
30-45 minutes
What are the side effects that can occur when taking cimetidine or famotidine
-Both: headache, diarrhea, constipation, drowsiness, dizziness
-Cimetidine: high doses may cause decreased libido, impotence or enlargement of breast tissue due to weak antiandrogenic effect
Who should avoid taking H2RA
-older adults: high risk for delirium, sodium-sensitive conditions
-those younger than 12 years old
-Okay to use in pregnancy, but studies suggest association of childhood asthma
-Famotidine preferred when lactating due to lower milk concentrations
What is the dosing on H2RA
-take at onset of symptoms OR 30 minutes prior to when HB is expected
-Cimetidine: 200mg once a day(may need adjustment due to kidney dysfunction)
-Famotidine: 10-20 mg once or twice daily(max 40mg in 24 hr)
What is the MOA of PPIs
inhibit hydrogen potassium ATPase in stomach parietal cells
What is the indication for PPIs
heartburn symptoms that happen 2 or more days per week
How long does it usually take for someone taking PPIs to see an effect
relief should start within 1-3 hours but can take up to 1-4 days for full effect to occur
What is the duration for a single dose of PPI
12-24 hours
What side effects can occur when taking a PPI
headache
abdominal pain
diarrhea
constipation
gas
*Increased risk for C. diff and travelers diarrhea
Who or when should PPIs be avoided
-avoid crush/chewing tablets or capsules
-if you have severe diarrhea/gastroenteritis symptoms
-younger than 18 years
-older adults(Beers list)
What is the dosing of PPIs
take 30-60 minutes prior to meal(most commonly breakfast)
take a max of 14 days(don’t have to take full 14 days, can see how you feel after 3-4 days)
1 course every 4 months
What is the MOA of Bismuth subsalicylate(Pepto-Bismol)
protects gastric mucosa
What is Pepto indicated for
nausea, heartburn, upset stomach, indigestion, diarrhea
How long does it take for Pepto to start working and how long do the effects last
onset: 30-60 min
duration: 30-60 min
What side effects can occur from taking Pepto
black-colored tongue/stool, tinnitus
What drug interactions exist with Pepto
warfarin
tetracycline antibiotics
methotrexate
Who should avoid taking Pepto
children younger than 18 y.o.(risk of Reyes syndrome)
salicylate sensitivity/allergy
bleeding risks
live vaccines
pregnant or lactating individuals
What is the dosing for pepto
262-525mg every 30-60 minutes as needed
*chew chewable tablets thoroughly
*take non-chewable tabs with full class of water
**TAKE FOR MAX 48 HOURS
If a pregnant person is experiencing heartburn, what are some things they can do to help?
-Make lifestyle/food changes first
-First-line OTC: calcium or magnesium antacids
**MAX food/OTC calcium per day should be 2500mg
What can be done for a child older than 2 years old experiencing mild, transient, infrequent HB or sour stomach
-take children’s formulation of calcium carb antacid and make food/lifestyle change
*Refer if frequent HB or antacid is ineffective
What is the MAX amount of daily calcium for children(including food/beverages)
Ages 2-3: 700mg
Ages 4-8: 1000mg
Ages 9-18: 1300 mg
When recommending treatments for older adults what should be taken into consideration?
-consider drug-drug interactions
-consider other health conditions and kidney function
-avoid H2RAs if high risk for delirium
-avoid long-term use of PPI due to risk of C. diff, fractures and other infections
*long-term use can be done under recommendation of DOCTOR
*triage carefully because HB may be symptom of a more serious pathology
