Module 2: GERD Covert

Question 1

What are the types of GERD?

Answer 1

-Non-erosive reflux disease: lack of erosions on scope (no erosions on endoscopy)

-Erosive reflux disease: erosions present on scope
-> typically with more symptoms, longer exposure to acid in the esophagus

Question 2

Symptoms

Answer 2

-Esophageal: Belching, Heartburn, Hypersalivation,
Regurgitation

-Extra-esophageal: Cough, Laryngitis, Asthma,
Enamel Erosion (teeth)

-Alarm Symptoms (Referral): Dysphagia, Odynophagia (painful swallowing)
-> might be signs of Barrett’s esophagus or esophageal cancer

Question 3

Risk factors

Answer 3

Modifiable
-Obesity (increases pressure to the abdomen, easier for food to reflux)
-smoking and EtOH (irritating and decreases the tone of the sphincter)
-Meds (certain meds increase the risk of GERD)
-Foods (spicy and greasy foods, more acid secretion)

Non-modifiable
-Family history, Meds, age over 40

Question 4

Meds causing worsening of GERD
decreasing lower esophageal sphincter (LES) tone:

Answer 4

-Anticholinergics
-Barbiturates (sedative-hypnotic for seizure)
-DHP CCBs!
-Dopamine
-Estrogens
-Nitrates
-Progesterone
-Tetracyclines!

Question 5

Meds causing worsening of GERD
Direct irritant

Answer 5

-Bisphosphonates
-Aspirin (baby dose 81mg) (may be non-modifiable, used after heart attack or stroke)
-NSAIDs
-Iron
-Potassium supplement
-Quinidine (antiarrhythmic)

Question 6

Complications of GERD (when untreated)

Answer 6

-Stricture (narrowing of the esophagus)
-Ulcer
-Mobility disorder (peristalsis becomes less effective)
-Perforation
-Hemorrhage
-Aspiration, Asthma
-Barrett’s esophagus (pre-cancer state)
-Esophageal adenocarcinoma

Question 7

Pharmacologic Treatment
Non-episodic GERD

Answer 7

-daily, consistent symptoms, regerdless of type and timing of meals

-8 week daily PPI

-Full response: slowly taper down and DC (every other day, every third day, every two days, depending on the patient’s response)

-if partial response -> increase the dose or change to BID, change PPI, add H2RA (ranitidine, famotidine) - patients may benefit from taking H2RA in the evening (histamine peaks in the evening)

-no response: REFER

Question 8

Why must PPIs be tapered off instead of dc abruptly?

Answer 8

patients may experience rebound hyper acid secretion

Question 9

Pharmacologic Treatment
Episodic GERD

Answer 9

-PRN antacids
-TUMS, Maalox
-act as a basic buffer

Question 10

When is long-term maintenance PPI therapy appropriate?

Answer 10

-patients who relapse after appropriate discontinuation of PPI

-Complications of GERD: Barrett’s esophagus and Esophageal adenocarcinoma

Question 11

Selecting PPI

Answer 11

-no evidence that one works better than the other

-available OTC:
Omeprazole (Prilosec)
Lansoprazole (Prevacid)
Omeprazole-sodium bicarb (Zegrid)
Esomeprazole (Nexium)

Pantoprazole (Protonix)
Rabeprazole (Aciphex)
Dexlansoprazole (Dexilant)

Question 12

Consolation points

Answer 12

-Take 30 min before a meal
-exception for
Omeprazole-sodium bicarb (Zegrid)
Dexlansoprazole (Dexilant)

-> for patients who have an inconsistent meal or are not likely to adhere to taking it 30 min before a meal

Question 13

Other Meds

Answer 13

-Sucralfate: coats the stomach, may prevent the absorption of other meds, NOT recommended in general, may be used in pregnancy and severe reflux

-Prokinetic agents: fe. metoclopramide - helps to move food more quickly, generally NOT recommended, may be used in refractory GERD

Question 14

PPI Drug Interactions

Answer 14

-Azole Antifungals: Itraconazole, Posaconazole - they require an acidic environment to be absorbed - decrease in absorption when PPIs are used

-Clopidogrel requires CYP2C19 to be activated, CYP2C19 is inhibited by omeprazole (Priolosec) and esomprazole (Nexium)

Question 15

Long-term side effects

Answer 15

-B12 deficiency: in elderly and long-term use (not clear evidence that it is caused by PPI

-Osteoporosis/Osteopenia: due to a decrease in Ca absorption in long-term use (not sure)

-increased risk of community-acquired pneumonia, by altering the gut microbiome -> increase in intra-gastric aerobic bacteria (good evidence)

-increased risk of C. diff due to the gastric pH being more basic (less killing of C. diff spores)
-> avoid PPI in patients with risk or history of C. diff (good evidence)

-dementia (not great evidence)

-higher risk of MI and cardiovascular death in Plavix and Non-Plavix patients (moderate evidence)

-AKI (renal), CKD (not clear)

Question 16

What are appropriate reasons to avoid PPIs based on the evidence?

Answer 16

-Drug interactions: Azole Antifungals, Clopidogrel (CYP2C19)
-CAP (gut microbiome change, aspiration to the lungs)
-C. diff (gastric pH goes up, decreases C. diff killing)

Question 17

What are the symptoms in GERD indicating a referral?

Answer 17

Dysphagia
Odynophagia

difficulty or painful swallowing

Question 18

Which PPIs inhibit CYP2C19?

Answer 18

Omeprazole (Prilosec)
Esomeprazole (Nexium)

Question 19

Typical meds to lower LES tone?

Answer 19

DHP CCB: Amlodipine, Nifedepine, Felodipine

Tetracycline: Doxycycline