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PHRM 504 > Lecture 13: Heartburn/Dyspepsia > Flashcards

Lecture 13: Heartburn/Dyspepsia Flashcards

1
Q

Dyspepsia

A

A constellation of upper abdominal symptoms
-Bothersome postprandial fullness, early satiation,
epigastric burning, epigastric pain

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2
Q

Pyrosis

A

“Burning feeling” in stomach or lower chest when

acid comes into contact with esophagus lining

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3
Q

Gastroesophageal Reflux Disorder (GERD)

A

Chronic symptoms occurring ≥ 2 times per week

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4
Q

Peptic Ulcer Disease

A

Erosion in the lining of the gastrointestinal tract (GIT) Gastric or duodenal ulcers

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5
Q

Physiology: Defense Mechanism

A

Anti-reflux barriers
Esophageal acid clearance
Tissue resistance

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6
Q

Antireflux barriers

A

Lower esophageal sphincter (LES)
Relaxes on swallowing: food -> stomach

When you swallow food, the LES relaxes which allows the food to enter the stomach

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7
Q

Esophageal acid clearance

A

Gravity
Peristalsis- involuntary constriction and relaxation of the muscle in the intestines which moves food through the digestive tract

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8
Q

Tissue resistance

A

• Esophageal blood supply maintains
acid-base balance
• Delivers bicarbonate, nutrients, oxygen
• Removes carbon dioxide, hydrogen

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9
Q

Gastroesophageal reflux disease

A

Occurs when esophageal sphincter does not close properly. This allows food or acid reflux to wash back up into your esophagus which causes irritation.
- Some treatments are OTC ad prescription antacid medications, diet and lifestyle changes, and surgery

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10
Q

What cause irritation and injury (symptoms)

A

Excessive reflux of gastric substances and breakdown of defensive mechanisms

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11
Q

Risk factors of heartburn: Food

A

Food such as chocolate, coffee, tea, citrus, tomatoes, garlic, onions, peppers and mint

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12
Q

Risk factors of heartburn: Medications

A

Medications:

  • Anticholinergic
  • Aspirin, NSAIDs
  • Iron
  • Nicotine
  • Alcohol
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13
Q

Risk factors of heartburn: Others

A
  • Alcohol
  • Family history
  • Genetics
  • Obesity
  • Pregnancy
  • Stress
  • Supine body position
  • Tight-fitting clothing
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14
Q

Which of the following is an anticholinergic adverse effect?

a. Bradycardia
b. Diarrhea
c. Dry moth
d. Increased urination

A

c. Dry mouth

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15
Q

Which of the following medications has anticholinergic properties?

a. dextromethorphan
b. diphenhydramine
c. Gaviscon
d. guafenesin

A

b. diphenhydramine

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16
Q

Clinical Presentation: Heartburn

Typical Symptoms

A
  • Pyrosis
  • Belching
  • Hypersalivation
  • Regurgitation
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17
Q

Clinical Presentation: Heartburn

Atypical Symptoms

A
  • Asthmatic symptoms
  • Chest pain
  • Chronic cough
  • Dental erosions
  • Globus sensation
  • Hoarseness
  • Laryngitis
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18
Q

Clinical Presentation: Heartburn

Alarm Symptoms

A
  • Dysphagia
  • GI bleeding
  • Odynophagia
  • Unexplained weight loss
  • Vomiting
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19
Q

Clinical Presentation: Dyspepsia

Typical Symptoms

A
  • Early satiation
  • Epigastric burning
  • Epigastric pain
  • Postprandial fullness
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20
Q

Clinical Presentation: Dyspepsia

Associated Symptoms

A
  • Belching
  • Bloating
  • Nausea
  • Vomiting
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21
Q

Clinical Presentation: Dyspepsia

Alarm Symptoms

A
  • Anemia
  • Blood loss
  • Dysphagia
  • Weight loss
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22
Q

Exclusions to self care: heartburn/ dyspepsia

A
  • Frequent heartburn for ≥ 3 months
  • Heartburn while taking recommended dosages of
    nonprescription H2RAs or PPIs
  • Heartburn that continues after 2 weeks of treatment with a
    nonprescription H2RA or PPI
  • Heartburn and dyspepsia that occur when taking a
    prescription H2RA or PPI
  • Severe heartburn or dyspepsia
  • Nocturnal heartburn ( at night)
  • Difficulty or pain when swallowing solid foods
  • Vomiting up blood or black material or passing black tarry
    stools
  • Chronic hoarseness, wheezing, coughing, or choking
  • Unexplained weight loss
  • Continuous nausea, vomiting, or diarrhea
  • Chest pain accompanied by sweating, pain radiating to
    shoulder, arm, neck, or jaw, and shortness of breath
  • Children < 2 years (for antacids)
  • < 12 years for H2RAs
    -< 18 years for PPIs
  • Adults > 45 years with new-onset dyspepsia
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23
Q

Goals of Self-Treatment

A
  1. Provide complete relief of symptoms.
  2. Reduce recurrence of symptoms.
  3. Prevent and manage unwanted effects of medications
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24
Q

Non-Pharmacologic Therapy

A
  • Avoid trigger foods and beverages
  • Eat ≥ 3 hours before bed/lying down
  • Elevate head of bed
  • Reduce size of meals
  • Smoking cessation
  • Weight loss

These measures should be recommended for ALL patients

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25
Q

Pharmacologic Therapy options

A

Antacids
H2RAs
PPIs

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26
Q

Antacids taken for

A
  • mild, infrequent, heartburn, dyspepsia

- rapid relief of symptoms

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27
Q

H2RAs taken for

A
  • Mild-moderate, episodic heartburn and dyspepsia
  • More prolonged relief of symptoms
  • Prevent heartburn and dyspepsia
  • Give 30 minutes to 1 hour prior to anticipated symptoms
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28
Q

PPIs taken for

A
  • Frequent heartburn and dyspepsia ( ≥ 2 days per week)
  • Nonresponse to H2RAs- symptoms don’t go away w H2RAs
  • Complete relief of symptoms may take several days
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29
Q

Antacids options

A
  • Various salts
  • Aluminum: hydroxide, phosphate
  • Calcium: carbonate
  • Magnesium: carbonate, hydroxide, trisilicate
  • Sodium: bicarbonate
30
Q

Antacids Brand Name

A 
Gaviscon
Maalox
Mylanta
Rolaids
Tums
31
Q

Antacids MOA

A

Neutralize gastric acid (buffering agents)

32
Q

Antacids PK

A

Onset: less than 5 min
Duration: 20-30 mins (prolonged by food in the stomach)

33
Q

Antacids Contraindications

A 
Calcium supplements (sodium bicarbonate)
- Hypersensitivity
34
Q

Antacids Precautions

A 
Renal imparment (for all salt forms)
- Risk of fluid overload ( sodium bicarbonate)
35
Q

Antacids Adverse effects

A

Generally well tolerated
Aluminum-containing: Constipation
Calcium Carbonate/ Sodium Bicarbonate: belching; flatulence
Magnesium-containing: Diarrhea

36
Q

Antacids Drug interactions

A

Fluoroquinolone/tetracycline antibiotics; pH dependent medications

37
Q

Antacids Dosing

A
  • Use product-specific recommendations at onset of symptoms
  • May repeat in 1-2 hours, if needed
  • Do not exceed maximum daily dosage
38
Q

Antacids Special Pops

A
  • Breastfeeding: Al, Ca, Mg considered safe
  • Children: calcium carbonate > 2 years
  • Pregnancy: Ca, Mg considered safe
39
Q

H2RAs Drugs agents

A

Cimetidine- Tagamet : 200 mg, MDD: 400mg
Famotidine- Pepcid AC: 10-20 mg, MDD 40 mg
Ranitidine- Zantac: 75-150 mg, MDD 300mg

40
Q

H2RAs MOA

A

Inhibit histamine on the histamine type 2 receptor of the parietal cell. This decreases fasting and food-stimulated gastric acid secretion and gastric volume

41
Q

H2RAs PK

A

Onset: 30-45 minutes
Duration: 4-10 hours

42
Q

H2RAs Contraindications

A

Hypersensitivity

43
Q

H2RAs Precautions

A

Advanced age; renal impairment

44
Q

H2RAs Adverse Effects

A

Generally well tolerated

Constipation; diarrhea; dizziness; drowsiness; headache

Rare, but serious: thrombocytopenia

45
Q

H2RAs Drug Interactions

A
  • pH dependent medications
  • Cimetidine: inhibits several P450 enzymes resulting in numerous interactions:
    ex: amiodarone; phenytoin; tricyclic antidepressants; warfarin
46
Q

H2RAs Dosing

A
  • Take by mouth 30-60 minutes prior to foods/beverages that cause heartburn
  • Limit to no more than 2 doses/day
  • Preferable to take as needed
47
Q

H2RAs Special pops

A
  • Advanced age/renal impairment: lower doses are recommended
  • Breastfeeding: famotidine preferred
  • Children: ≥ 12 years
  • Pregnancy: compatible
48
Q

H2RAs: Concerns

A

Nitrosamine impurity – N-nitrosodimethylamine (NDMA)

- Probable human carcinogen

49
Q

Process of removing H2RAs from market

A
  • September 2019:
    • First voluntary recall of specific lots of product
  • October 2019
    • Food and Drug Administration (FDA) launched investigation
    • Manufacturers to conduct laboratory testing to examine NDMA levels and
    send samples to FDA
  • December 2019: FDA expands testing to ALL lots before available to consumers
    FDA, 2020.
    H2RAs: Concerns
  • April 1st, 2020
    • “FDA Requests Removal of All Ranitidine Products (Zantac) from
    the Market”
    • ALL prescription and OTC ranitidine drugs
    • NDMA in some products increases over time and when stored at higher
    than room temperatures
    • May result in consumer exposure to unacceptable levels of this impurity
50
Q

PPIs Agents

A
  • Esomeprazole (Nexium 24HR®): 20 mg, MDD 20 mg
  • Lansoprazole (Prevacid 24HR®): 15 mg, MDD 15 mg
  • Omeprazole (Prilosec OTC®): 20 mg , MDD 20 mg
51
Q

PPIs PK

A

Onset: 1-3 hours
Duration: 12-24 hours

52
Q

PPIs Contraindications

A

Hypersensitivity

53
Q

PPIs Precautions

A

Hepatic impairment ; renal impairment

54
Q

PPIs Adverse Effects

A

Constipation; diarrhea; headache

55
Q

PPIs Drug Interactions

A
  • pH dependent medications

- CYP2C19 substrates: ex. clopidogrel, phenytoin, warfarin, pH dependent medications

56
Q

PPIs Dosing

A
  • Take by mouth with a glass of water 30 minutes before breakfast
  • Take daily for 14 days
  • May be repeated every 4 months
57
Q

PPIs Special Pops

A
  • Breastfeeding and pregnancy: limited data available

- Children: ≥ 18 years

58
Q

PPIs MOA

A

Binds to and Inhibits hydrogen potassium ATPase (proton pump) which irreversibly blocks gastric acid secretion

59
Q

PPIs Concerns

A

Chronic acid suppression:
• Potential to increase infection risk
• Bacterial gastroenteritis, Clostridium difficile, community-acquired
pneumonia

High-dose, long-term (> 1 year) use can cause:
- Increased risk hip, spine, wrist fractures (patients > 50 years)

Long-term use can cause
- Hypomagnesemia, iron malabsorption, vitamin B12 deficiency
• Newer studies:
- Associated with risk of dementia
- Increased risk of chronic kidney disease (CKD)

60
Q

Bismuth Salicylate Brand Name

A

Pepto-Bismol®

61
Q

Bismuth Salicylate MOA

A

Unknown for relief of heartburn

62
Q

Bismuth Salicylate Contraindications

A

Hypersensitivity

63
Q

Bismuth Salicylate Precautions

A

Bleeding disorders; children; pregnancy; renal failure

64
Q

Bismuth Salicylate Adverse Effects

A

Fecal discoloration (gray-black); tongue discoloration (darkening)

65
Q

Bismuth Salicylate Dosing

A
  • 262-525 mg by mouth every 30-60 minutes as needed

- MDD 8 doses (262 mg), 4 doses (525 mg

66
Q

Patient Education for Antacids

A
  • Use for relief of mild, infrequent symptoms

- Take at onset of symptoms

67
Q

Patient Education for H2RAs

A
  • Take at onset of symptoms or 30-60 minutes before symptoms are expected
68
Q

Patient Education for PPIs

A
  • Take with a full glass of water every morning 30 minutes before breakfast for 14 days
  • Take the full 14-day course of treatment
  • Do not cut, crush, or chew tablets or capsules
69
Q

Evaluation of Patient Outcomes: Antacids

A
  • Reevaluate if using more than 2x/week or regularly for more than 2 weeks
  • Frequent users may need a longer-acting product
70
Q

Evaluation of Patient Outcomes: H2RAs

A

If treatment needed for more than 2 weeks, refer

71
Q

Evaluation of Patient Outcomes: PPIs

A
  • If treatment needed for more than 2 weeks, refer

- If symptoms recur within 4 months, refer

PHRM 504 (22 decks)

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