Lecture 13: Heartburn/Dyspepsia Flashcards
Dyspepsia
A constellation of upper abdominal symptoms
-Bothersome postprandial fullness, early satiation,
epigastric burning, epigastric pain
Pyrosis
“Burning feeling” in stomach or lower chest when
acid comes into contact with esophagus lining
Gastroesophageal Reflux Disorder (GERD)
Chronic symptoms occurring ≥ 2 times per week
Peptic Ulcer Disease
Erosion in the lining of the gastrointestinal tract (GIT) Gastric or duodenal ulcers
Physiology: Defense Mechanism
Anti-reflux barriers
Esophageal acid clearance
Tissue resistance
Antireflux barriers
Lower esophageal sphincter (LES)
Relaxes on swallowing: food -> stomach
When you swallow food, the LES relaxes which allows the food to enter the stomach
Esophageal acid clearance
Gravity
Peristalsis- involuntary constriction and relaxation of the muscle in the intestines which moves food through the digestive tract
Tissue resistance
• Esophageal blood supply maintains
acid-base balance
• Delivers bicarbonate, nutrients, oxygen
• Removes carbon dioxide, hydrogen
Gastroesophageal reflux disease
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
What cause irritation and injury (symptoms)
Excessive reflux of gastric substances and breakdown of defensive mechanisms
Risk factors of heartburn: Food
Food such as chocolate, coffee, tea, citrus, tomatoes, garlic, onions, peppers and mint
Risk factors of heartburn: Medications
Medications:
- Anticholinergic
- Aspirin, NSAIDs
- Iron
- Nicotine
- Alcohol
Risk factors of heartburn: Others
- Alcohol
- Family history
- Genetics
- Obesity
- Pregnancy
- Stress
- Supine body position
- Tight-fitting clothing
Which of the following is an anticholinergic adverse effect?
a. Bradycardia
b. Diarrhea
c. Dry moth
d. Increased urination
c. Dry mouth
Which of the following medications has anticholinergic properties?
a. dextromethorphan
b. diphenhydramine
c. Gaviscon
d. guafenesin
b. diphenhydramine
Clinical Presentation: Heartburn
Typical Symptoms
- Pyrosis
- Belching
- Hypersalivation
- Regurgitation
Clinical Presentation: Heartburn
Atypical Symptoms
- Asthmatic symptoms
- Chest pain
- Chronic cough
- Dental erosions
- Globus sensation
- Hoarseness
- Laryngitis
Clinical Presentation: Heartburn
Alarm Symptoms
- Dysphagia
- GI bleeding
- Odynophagia
- Unexplained weight loss
- Vomiting
Clinical Presentation: Dyspepsia
Typical Symptoms
- Early satiation
- Epigastric burning
- Epigastric pain
- Postprandial fullness
Clinical Presentation: Dyspepsia
Associated Symptoms
- Belching
- Bloating
- Nausea
- Vomiting
Clinical Presentation: Dyspepsia
Alarm Symptoms
- Anemia
- Blood loss
- Dysphagia
- Weight loss
Exclusions to self care: heartburn/ dyspepsia
- 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
Goals of Self-Treatment
- Provide complete relief of symptoms.
- Reduce recurrence of symptoms.
- Prevent and manage unwanted effects of medications
Non-Pharmacologic Therapy
- 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
Pharmacologic Therapy options
Antacids
H2RAs
PPIs
Antacids taken for
- mild, infrequent, heartburn, dyspepsia
- rapid relief of symptoms
H2RAs taken for
- 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
PPIs taken for
- 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
Antacids options
- Various salts
- Aluminum: hydroxide, phosphate
- Calcium: carbonate
- Magnesium: carbonate, hydroxide, trisilicate
- Sodium: bicarbonate
Antacids Brand Name
Gaviscon Maalox Mylanta Rolaids Tums
Antacids MOA
Neutralize gastric acid (buffering agents)
Antacids PK
Onset: less than 5 min
Duration: 20-30 mins (prolonged by food in the stomach)
Antacids Contraindications
Calcium supplements (sodium bicarbonate) - Hypersensitivity
Antacids Precautions
Renal imparment (for all salt forms) - Risk of fluid overload ( sodium bicarbonate)
Antacids Adverse effects
Generally well tolerated
Aluminum-containing: Constipation
Calcium Carbonate/ Sodium Bicarbonate: belching; flatulence
Magnesium-containing: Diarrhea
Antacids Drug interactions
Fluoroquinolone/tetracycline antibiotics; pH dependent medications
Antacids Dosing
- Use product-specific recommendations at onset of symptoms
- May repeat in 1-2 hours, if needed
- Do not exceed maximum daily dosage
Antacids Special Pops
- Breastfeeding: Al, Ca, Mg considered safe
- Children: calcium carbonate > 2 years
- Pregnancy: Ca, Mg considered safe
H2RAs Drugs agents
Cimetidine- Tagamet : 200 mg, MDD: 400mg
Famotidine- Pepcid AC: 10-20 mg, MDD 40 mg
Ranitidine- Zantac: 75-150 mg, MDD 300mg
H2RAs MOA
Inhibit histamine on the histamine type 2 receptor of the parietal cell. This decreases fasting and food-stimulated gastric acid secretion and gastric volume
H2RAs PK
Onset: 30-45 minutes
Duration: 4-10 hours
H2RAs Contraindications
Hypersensitivity
H2RAs Precautions
Advanced age; renal impairment
H2RAs Adverse Effects
Generally well tolerated
Constipation; diarrhea; dizziness; drowsiness; headache
Rare, but serious: thrombocytopenia
H2RAs Drug Interactions
- pH dependent medications
- Cimetidine: inhibits several P450 enzymes resulting in numerous interactions:
ex: amiodarone; phenytoin; tricyclic antidepressants; warfarin
H2RAs Dosing
- 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
H2RAs Special pops
- Advanced age/renal impairment: lower doses are recommended
- Breastfeeding: famotidine preferred
- Children: ≥ 12 years
- Pregnancy: compatible
H2RAs: Concerns
Nitrosamine impurity – N-nitrosodimethylamine (NDMA)
- Probable human carcinogen
Process of removing H2RAs from market
- 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
PPIs Agents
- Esomeprazole (Nexium 24HR®): 20 mg, MDD 20 mg
- Lansoprazole (Prevacid 24HR®): 15 mg, MDD 15 mg
- Omeprazole (Prilosec OTC®): 20 mg , MDD 20 mg
PPIs PK
Onset: 1-3 hours
Duration: 12-24 hours
PPIs Contraindications
Hypersensitivity
PPIs Precautions
Hepatic impairment ; renal impairment
PPIs Adverse Effects
Constipation; diarrhea; headache
PPIs Drug Interactions
- pH dependent medications
- CYP2C19 substrates: ex. clopidogrel, phenytoin, warfarin, pH dependent medications
PPIs Dosing
- Take by mouth with a glass of water 30 minutes before breakfast
- Take daily for 14 days
- May be repeated every 4 months
PPIs Special Pops
- Breastfeeding and pregnancy: limited data available
- Children: ≥ 18 years
PPIs MOA
Binds to and Inhibits hydrogen potassium ATPase (proton pump) which irreversibly blocks gastric acid secretion
PPIs Concerns
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)
Bismuth Salicylate Brand Name
Pepto-Bismol®
Bismuth Salicylate MOA
Unknown for relief of heartburn
Bismuth Salicylate Contraindications
Hypersensitivity
Bismuth Salicylate Precautions
Bleeding disorders; children; pregnancy; renal failure
Bismuth Salicylate Adverse Effects
Fecal discoloration (gray-black); tongue discoloration (darkening)
Bismuth Salicylate Dosing
- 262-525 mg by mouth every 30-60 minutes as needed
- MDD 8 doses (262 mg), 4 doses (525 mg
Patient Education for Antacids
- Use for relief of mild, infrequent symptoms
- Take at onset of symptoms
Patient Education for H2RAs
- Take at onset of symptoms or 30-60 minutes before symptoms are expected
Patient Education for PPIs
- 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
Evaluation of Patient Outcomes: Antacids
- Reevaluate if using more than 2x/week or regularly for more than 2 weeks
- Frequent users may need a longer-acting product
Evaluation of Patient Outcomes: H2RAs
If treatment needed for more than 2 weeks, refer
Evaluation of Patient Outcomes: PPIs
- If treatment needed for more than 2 weeks, refer
- If symptoms recur within 4 months, refer
