Lecture 63 Flashcards by Emma Kruyer

foods that decrease LES pressure

fatty meals
peppermint and spearmint
chocolate
coffee
soda
tea
garlic
onions
chili peppers
alcohol

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GERD risk factors

pregnancy
obesity
tobacco smoking
genetic predisposition
alcohol consumption
triggering medications and foods

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direct irritant foods

spicy foods
orange juice
tomato juice
coffee
tobacco

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medications that decrease LES pressure

anticholinergics
barbiturates
caffeine
DHP CCB
dopamine
estrogen and progesterone
nicotine
nitrates
tetracycline

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medications that are direct irritants

aspirin
bisphosphonates
NSAIDs
iron
quinidine
potassium chloride

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GERD symptoms

heartburn
regurgitation and belching
reflux chest pain
chronic cough
laryngitis
wheezing
asthma

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alarm symptoms of GERD

dysphagia (difficulty swallowing) –> odynophagia (painful swallowing) –> bleeding –> weight loss

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symptoms of GERD in children

refusing to eat
wheezing/coughing
dental erosion
recurrent regurgitation
irritability

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alarm symptoms of GERD in children

weight loss
fever
seizure
persistent vomiting and diarrhea

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complications of GERD

erosive esophagitis
stricture
barrett’s esophagus
adenocarcinoma of the esophagus

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Tums

calcium carbonate
OTC Dosing - 2 to 4 tablets prn for up to four times a day; max of 16 tablets per day
SE - constipation, NV, flatulence

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milk of magnesia

magnesium hydroxide
OTC Dosing - 5 to 15mL for up to four times a day; max of 60mL per day
SE - diarrhea, NV, flatulence

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Aluminum and magnesium

maalox
gaviscon (plus alginate acid)
could bring diarrhea or constipation
NV and flatulence

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famotidine

OTC Dosing - 10 to 20mg BID; max 40mg per day
RX Dosing - 10mg BID PRN; take 10-60 minutes before meals; if symptoms persist after 2-4 weeks increase to 20mg BID for 2 weeks —> persist, consider PPI
Renal adjustments if CrCL is under 50mL/min give 50% of dose

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Cimetidine

OTC/RX Dosing - 200mg daily up to 30 minutes before meals; max of 400mg per day
interacts with CYP1A2, 2C9, 2D6, and 3A4

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H2RA SE profiles

headache
dizziness and fatigue
constipation or diarrhea
somnolence and confusion
agitation
B12 deficiency

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H2RAs clinical pearls

BEERS criteria
used alone or in combo with other classes to treat mild to moderate GERD
all H2RAs are equally efficacious
not as effective as PPIs

omeprazole dosing

OTC - 20mg qd x14d, may repeat in 4 months
RX - 10 to 40mg qd
no renal adjustments
administer 30 to 60 minutes before first meal of day

pantoprazole dosing

PO RX - 20 to 40mg qd
IV RX - 40mg qd
No renal adjustments
administer 60 minutes before first meal of day

Esomeprazole dosing

OTC - 20mg qd x14d, may repeat in 4 months
PO/IV RX - 20 to 40mg QD
no renal adjustments
administer 30 to 60 minutes before first meal of day

Lansoprazole Dosing

OTC - 15mg qd x14d, may repeat in 4 months
RX - 15 to 30mg qd
no renal dose adjustments
ODT available

dexlansoprazole (dexilant) dosing

RX only if complications, 60mg qd x8w then 30mg indefinitely; if no complications, 30mg qd
no renal adjustments
dual release formulation with onset in 1-2 hours and again at 4-5 hours

rabeprazole dosing

RX - 10 to 20mg qd
no renal dose adjustments
administer 30 minutes before first meal of the day

PPI short term SE

headache
dizziness
diarrhea, flatulence
nausea, abdominal pain
enteric infections
community acquired pneumonia

PPI long term SE

hypomagnesemia bone density decrease/fractures vitamin b12 deficiency chronic kidney disease

increased effects of PPI

through methotrexate, phenytoin, warfarin

decreased effects of PPI

through iron, bisphosphonates, HIV/HCV drugs, clopidogrel

PPI clinical pearls

initial treatment duration should last no more than 8 weeks on RX PPI and 14 days on OTC PPI maximize therapy by increasing dose, frequency, or switching PPIs BEERS criteria recommended taper after long-term therapy

promotility agents

metoclopramide bethanechol may be used as adjunct therapy if there is a known motility defect in GERD not as effective as acid suppression therapy and have undesirable side effects

mucosal protectants

sucralfate limited use in treatment of GERD but may be useful for management of radiation esophagitis and nonacid reflux GERD

antacid and H2RA combination therapy

may be helpful for heartburn after meals pepcid ac - famotidine and calcium carbonate/magnesium

PPI and H2RA combination therapy

nighttime dose of H2RA can help with overnight acid production H2RA can provide breakthrough relief in patients on PPI

nonpharm treatments for GERD

lifestyle modifications (weight loss, sleep with head elevated, avoiding late meals, avoiding triggers, portion control, exercise) and surgical management

antireflux surgery

consider when long-term pharmacotherapy is undesirable or when patients have complications reinforces the LES reduces regurgitation and acid backflow

OTC patient guided GERD

no alarm symptoms mild to moderate new onset identifiable triggers minimized

medical referral GERD

presence of alarm symptoms OTC trial for 14 days with no relief

treatment of GERD in pregnancy

recommend lifestyle changes prior to pharmacologic options 1st - antacids that do not contain aspirin 2nd - H2RAs last line - severe or refractory cases

treatment of GERD in lactation

antacids - lacking data but considered generally acceptable H2RAs - excreted in breast milk at low amounts PPIs - excretion into breast milk is minimal; most data on pantoprazole and omeprazole

non-pharmacologic treatment of GERD in childrens

thickening formula and foods decreasing volume of intake milk free diet positioning therapy

pharmacologic treatments of GERD in children

PPIs and H2RAs (treat for 4-8w, only for diagnosed GERD or esophagitis) antacids (not used chronically; no aluminum or BSS) Simethicone and Probiotics (safe and otc) Herbal options (ginger ale, chamomile, peppermint)