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OTC II > Heartburn > Flashcards

Heartburn Flashcards

1
Q

What is the definition of eCare?

A

An interoperable standard for pharmacy providers to have a method of exchanging information
-> related to:
-patient goals
-health concerns
-active medication list,
-drug therapy problems
-laboratory results
-vitals
-payer information and billing services

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2
Q

What is Interoperability?

A

Commonly agreed to a way of communicating data

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3
Q

Reasons to use eCare?

A

-Lowering the number of miscommunications and medical errors (writing, speaking)
-assuring the message actually received by the physician

-follow up and monitoring
-prevention of chronic disease by optimizing medication use

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4
Q

Goals of eCare

A

-informed decision-making at all levels of patient care
-focused on the pharmacist-physician documentation

-Medication Therapy Problem
-Patient Goals
-Interventions

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5
Q

What are possible factors contributing to heartburn?

A

-Spicy food
-Alcohol
-eating shortly before going to bed
-NSAIDs
-Overweight
-No activity -> Exercise is preventative

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6
Q

Function of the lower esophageal sphincter (LES)

A

-Permits passage of food into the stomach
-Contracted at rest
-Transient relaxation in healthy individuals
-The damage caused by gastric content is reduced due to mucosal resistance of the esophageal

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7
Q

How is the content cleared from the esophagus?

A

Peristalsis, Saliva, gravity

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8
Q

What alters the tightness of the LES?

A

-Age
-Medication
-Pressure (obesity, pregnancy)

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9
Q

Clinical Presentation: Heartburn

A

-Pressure arising from the lower chest
-feeling that food is coming up
-belching

How often?
Mild: infrequent, episodic -> diet or lifestyle
Frequent: 2 days or more per week !!! EXAM

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10
Q

What causes the relaxation of LES when not supposed to?
Pathophysiology

A

-Stimulation of sensory nerve endings in the esophagus
-> Spicy foods or reflux of gastric contents into the esophagus

-noxious quality of gastric contents: refluxed bile, gastric enzymes
-Esophageal tissue damage: due to bile, pepsin, gastric acid

-pressure
-impaired peristalsis (fe slowed gastric emptying (drug: GLP-1), saliva: reduced clearing of refluxed content from the esophagus

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11
Q

Factors contributing to heartburn

A

-Diet
-Constipation
-Isometric exercises
-Lifestyle: No Exercising, smoking, anxiety, obesity
-Genetics, pregnancy

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12
Q

Meds contributing to heartburn

A

-Aspirin/NSAIDs
-Vitamin C (high dose can aggravate acid reflux due acidity)
-Iron supplements
-many more…

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13
Q

What is the frequency of symptoms in GERD?

A

Frequent and persistent: 2 or more days per week
-> Symptoms / Esophaegal damage

-should be REFERRED

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14
Q

What are the typical symptoms of GERD?

A

-Heartburn, acid regurgitation (acid taste in
mouth), hypersalivation

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15
Q

What are the alarming symptoms of GERD?

A

-Dysphagia (difficulty swallowing)
-odynophagia (pain when swallowing)
-chest pain
-upper GI bleeding
-unexplained
-weight loss
-nausea, vomiting, diarrhea

-> REFERRAL

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16
Q

What are the diseases GERD can turn into?

A

-Erosive esophagitis
-Strictures (difficulties eating, swallowing)
-Bleeding
-Barrett’s esophagus
-Esophageal cancer

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17
Q

Dyspepsia

A

Subjective feeling of discomfort primarily in the upper abdomen

-> associated with epigastric pain, burning, fullness after a meal, earl satiety

LESS commonly belching, bloating, nausea and vomiting

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18
Q

Peptic ulcer disease (PUD)

A

-Gnawing or burning epigastric pain
-maybe together with heartburn and dyspepsia
-erosive (ätzend) component
-REFER -> longer treatment

during the day, and frequently at night

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19
Q

Exclusion self-treatment heartburn

A

-heartburn for more than 3 months
-heartburn while on OTC PPI
-self-treatment for 2 weeks but still heartburn
-severe heartburn and dyspepsia
-Nocturnal (at night) heartburn
-Odynophagia/dysphagia (difficulty swallowing)

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20
Q

More exclusions

A

-Coffee ground emesis (coughing of dark coagulated blood)/melena (black stool)
-Chronic hoarseness, wheezing, coughing, choking
-weight-loss
-N/V/D
-cardiac chest pain
-pregnancy, children

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21
Q

Non-pharmacological therapy

A

-reduce fat intake, decrease portion size
-weight-loss
-elevating the head of the bed
-avoid food/drinks 3 hours before going to bed
-avoid irritating medication
-smoking cessation
-limit alcohol and caffeine

22
Q

What are the pharmacologic therapies?

A

-Antacids (Bow and Arrow)
-Histamine2-Receptor Antagonists (H2RAs) (Rifle)
-Proton Pump Inhibitors (PPIs) (Rocket Launcher)
-Bismuth subsalicylate

23
Q

Antacids

A

-short-term effect (but pt have to take it often, they get tired over time) -> 4x per day (MAX: 2 weeks)

-mild, infrequent heartburn/dyspepsia

24
Q

API Antacids

A

-Sodium bicarbonate NaHCO3
-Calcium carbonate CaCO3
-Magnesium hydroxide MgOH2
-Aluminum hydroxide AlOH3
(Available alone and in combination)

25
Q

Antacids MOA, Onset, Duration

A

-MOA: neutralizes acid in the stomach
-Onset: 5 minutes (liquid faster than tablet)
-Duration: 20-30 min (longer with food)
Al and Ca are slightly longer than Mg and Bicarb
-Minimal systemic absorption (<30%)

26
Q

Adverse effects of Antacids

A

-Mg-containing: diarrhea (avoid: CrCl <30)
-Al-containing: constipation
-Ca-containing: belching, flatulence, constipation
-Sodium bicarbonate: belching, flatulence, high sodium
-caution in renal impairment (toxicity, renal calculi)

27
Q

Drug Interactions

A

-increase or decrease absorption of other drugs
-> Antimicrobials, iron (chelation process)

28
Q

Histamine2-Receptor Antagonists

A

-Cimetidine (a lot of side effects)
-Famotidine
-Nizatidine
-Ranitidine (FDA-recommended removal) - ingredient NMDA

29
Q

What are Histamine2-Receptor Agonists used for?

A

-mild-to-moderate, infrequent, episodic heartburn and dyspepsia
– Treatment of PUD (Rx only)

-Usually once or twice daily for up to 2 weeks
can develop tolerance

30
Q

MOA, Duration, Onset of H2RA

A

-MOA: Inhibit H2 receptors on parietal cells to decrease gastric acid secretion and gastric volume

-Onset: 30-60 min (longer on full stomach)
-Duration: 4-10 hours
-Dosing: every 12 hours or once a day

31
Q

Adverse reactions of H2RA

A

-Rare - easy to tolerate
-Headache, diarrhea, constipation, dizziness, drowsiness
-Thrombocytopenia is rare

32
Q

Drug interaction of H2RA

A

-Cimetidine potent inhibitor of CYP450
-Cimetidine associated with weak antiandrogenic effect

33
Q

What are PPIs used for?

A

-frequent heartburn, PUD (Rx only)

-Lansoprazole (Prevacid 24hr) 15 mg daily (max 2 weeks)
-Omeprazole (Prilosec OTC) 20 mg daily (max 2 weeks)
-Esomeprazole (Nexium 24hr)

34
Q

When should patients take PPIs?
EXAM!!!

A

30 minutes before the heaviest meal of the day
-should be consistently at the same time of the day

35
Q

MOA, Onset, Duration of PPIs

A

-MOA: Irreversibly inhibits proton pump (H+/K+ ATPase)
-Onset: 2-3 hours
-Duration: 12-24 hours
Optimal benefit of effect: 1-4 days

36
Q

Adverse effects

A

-RARE
-Diarrhea
-Constipation
-Headache

37
Q

What are the drug interactions of PPIs?

A

-Omeprazole:
may decrease the effects of clopidogrel
may increase the effects of Warfarin

-Lansoprazole
May decrease the effects of clopidogrel

38
Q

Risks associated with PPIs

A

-depletion of nutrients: Ca, Mg, Iron, B12 (easy to replace with a single multivitamin)
-> low Ca -> Fractures: risk for hip, spine, and wrist fractures in older patients (>50 years)

-Infections: Cdiff and bacterial gastroenteritis; Community-acquired pneumonia

-Rebound acid hypersecretion

39
Q

How can Rebound acid hypersecretion be avoided?

A

-reduce high doses slowly before discontinuing the drug

40
Q

What are the symptoms associated with PPI long-term use?

A

-Long-term: 4-5 years
-Dementia
-Chronic Kidney disease

41
Q

Bismuth Subsalicylate MOA

A

MOA: unknown; Antisecretory effects may help relieve upset stomach

42
Q

Indications of Bismuth Subsalicylate

A

-Nausea, diarrhea
-heartburn
-indigestion
-upset stomach

262 – 525 mg every ½ to 1 hour PRN

43
Q

Adverse effects of Bismuth Subsalicylate

A

-Contains salicylate (not for children under 12; or 16)
-Caution in children with flu-like illness (Reye’s Syndrome)
-May turn stool and tongue black
-bleeding risk

44
Q

What do look out for in patients taking Bismuth Subsalicylate?

A

-renal impairment
-> Caution use antacids (contain Al, Mg), reduce daily dose of H2R

-interacting medications
-individualize medication choice to the patient

45
Q

Heartburn medication in pregnant women?

A

-<12 -> REFER (but Antacids should be fine unless it is chronic)
-Antacids with Mg and Al are safe
-H2RAs are Category B
-other products under physician supervision

-Nursing mother (breast-feeding) - REFER

46
Q

Drug to use -> Mild, infrequent heartburn and dyspepsia requiring immediate relief

A

Antacids, H2RAs
no longer than 2 weeks

47
Q

Mild-to-moderate, episodic heartburn requiring prolonged relief

A

H2RA
no longer than 2 weeks

48
Q

Mild-to-moderate: requiring both immediate and prolonged relief

A

Combination of Antacid and H2RA
no longer than 2 weeks

49
Q

Frequent heartburn or no response to H2RAs

A

PPI
no longer than 2 weeks without provider supervision

50
Q

What is the duration of frequent untreated heartburn that excludes patients from self-treatment?

A

3 months

51
Q

Population of patients to exclude by age

A

<12 or older than 45

52
Q

What are the risk factors for GI distress?

A

-60y or older
-patients with a history of GI ulcers or bleeding problems
-anticoagulants (warfarin), systemic steroids, NSAIDs
-3 alcoholic beverages daily

OTC II (17 decks)

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