Lecture 12 GERD Flashcards
What are the presentations of GERD?
erosive esophagitis seen on endoscopy - develops in pt with GERD when acid and inflammation injure the esophagus,
endoscopy negative reflux disease (ENRD) - normal esophagus on endoscopy (ex. NERD)
makes up majority of GERD pt (30-70%)
What are exclusions for self tx of GERD?
heartburn sx ⇒ > 3 months, nocturnal, continues after 2 weeks of OTC H2RA or PPI, occurs when taking Rx H2RA or PPI
new onset > 50-55
dysphagia or odynophagia
GI bleeding (hematemesis, black stool, anemia)
sx of laryngitis ⇒ hoarseness, wheeze, cough, choking,, unexplained weight loss
continuous N/V/D
sx suggestive of cardiac chest pain
pregnant or nursing women
children <12 for antacids/H2RA, <18 for PPI
FHx of GI cancer
How should GERD be managed?
lifestyle modification ⇒ weight loss if overweight, elevation of head of bed for HS sx, possible change to trigger foods in det, avoiding meals 2-3 hours before bed, smoking cessation, reducing alcohol and coffee, smaller meals, + pantoprazole 40 mg QD F4W with 1 refill, assess from there
don’t maintain long term therapy without an attempt to reduce/stop tx once yearly in appropriate pt
What is the recommended management of erosive esophagitis?
an 8 week course of PPI for sx relief and healing of erosive esophagitis
step down tx with H2RA is not appropriate
What PPIs does ABC cover?
covers only the lowest cost generic versions of rabeprazole and pantoprazole, with MAC pricing for others
What are tips for patients for PPI usage?
should be administered 30-60 minutes before meal rather than at bedtime for GERD control, if QD then before breakfast, if BID then breakfast and supper
What is refractory GERD, how might it be caused, and how should it be managed?
it is persistent GERD sx despite 8-12 weeks of double dose PPI
Cause: inadequate acid suppression, reflux hypersensitivity, incorrect diagnosis, sx are functional
Management: compliance, timing, double dose, switch
might consider a switch to PPI that doesn’t rely on CYP2C19 for primary metabolism ⇒ like rabeprazole
Antacids for GERD (PK, dose, intx)
should only be used ‘on demand’ for mild GERD sx occurring <1/week
fast relief (faster than H2RA and PPI) onset 5 mins and last for 30-60 min
don’t promote healing of esophagus
Dose; take prn q30-60 min
Intx: iron, sulfonylurea, quinolones, levothyroxine
When is maintenance tx with PPIs indicated for GERD/ENRD complications?
sx relapse after low dose or discontinuation
severe erosive esophagitis
Barrett’s esophagus
chronic NSAID users with bleeding risk
documented hx of bleeding peptic ulcer
Which patients should be screened/tested for H. pylori?
pt with dyspepsia sx, pt with current or past gastric or duodenal ulcers or upper GI bleed, pt with personal or first degree relative with hx of gastric cancer, first gen immigrants from Asia, Africa, Central and South America
How does prevention of NSAID ulcer complications look tx wise?
Low CV risk: if Low GI risk ⇒ NSAID alone (least ulcerogenic at lowest dose), if Moderate GI risk ⇒ NSAID + PPI/misoprostol, if High GI risk ⇒ alternative tx or COXIB + PPI/misoprostol
High CV risk (LD ASA): if Low GI risk ⇒ naproxen + PPI/misoprostol, if Moderate GI risk ⇒ naproxen + PPI/misoprostol, if High GI risk ⇒ avoid NSADIs or COXIBs, use alternative tx
