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Therapeutics > 63: GERD > Flashcards

63: GERD Flashcards

1
Q

GERD

A

-reflux tummy contents into esophagus or lung

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2
Q

GERD epidemiology

A

-pt 50 and older
-20% of US adults
-prevalence of erosive esophagitis, barret’s esophagus and adenocarcinoma higher in men

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3
Q

Contributing factors to GERD

A

-pregnancy
-obesity
-tobacco smoking
-gene predisposition
-alcohol consumption
-triggering meds and food

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4
Q

GERD patho

A

-abnormal esophageal clearance
-dec LES pressure
-emptying + ab pressure
-acid pocket formation
-mucosal resistance

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5
Q

Foods that dec LES pressure

A

-fat
-mint
-chocolate
-coffe, soda, tea
-garlic
-onions
-chili peppers
-alcohol

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6
Q

Foods that are direct irritants for GERD

A

-spicy
-orange juice
-tomato juice
-coffe
-tobacco

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7
Q

Meds that dec LES pressure

A

-anticholinergics
-barbituates
-caffeine
-DHP
-Dopamine
-estorgen/progesterrone
-nictotine
-nitrates
-tetracycline

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8
Q

Meds that are direct irritant to GERD

A

-arpirin
-bisphosphonates
-NSAIDs
-iron
-quinidine
-potassium chloride

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9
Q

GERD presentation

A

-symptom based + esophageal injury
-extraesophageal

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10
Q

Symptom-based GERD presentation

A

-heartburn
-regurgitation and belching
-reflux chest pain

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11
Q

Extraesophageal GERD presentation

A

-chronic cough
-laryngitis
-wheezing
-asthma

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12
Q

GERD alarm symptoms

A

-dysphagia
-odynophagia
-bleeding
-weight loss

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13
Q

Diagnosing GERD

A

-Upper endoscopy
-Ambulatory reflux monitoring
-Manometry/Pressure Topography
-Barium Radiography

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14
Q

Upper Endoscopy

A

-preferred
-indicated for presistent GERD, alarm symptoms, barrets, pH, endoscopic procedures

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15
Q

Ambulatory reflux monitory +/- impedance

A

-useful for pts not responding to acid suppression therapy when endoscopy is normal or extraesophageal symptoms
-asses exposure time
AET: 0<4% is normal >6% is abnormal

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16
Q

Manometry/High-res esophageal topography

A

-useful in those who failed BID PPI therapy w normal endoscopic findings

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17
Q

Barium Radiography

A

-useful in detecting hiatal hernia
-not routinely used to diagnose GERD bc it lack sensitivity and specificity

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18
Q

Complications of GERD

A

-erosive esophagitis
-stricture
-barret’s esophagus
-adenocarcinoma

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19
Q

GERD goals of care

A

-relieve symptoms
-dec freq of acid reflux
-promote healing of injured mucosa
-prevent complications related to GERD

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20
Q

GERD treatment overview

A
  1. Lifestyle
  2. PRN rxs (antacids and H2RAs
  3. scheduled rxs (H2Ras and PPIs)
  4. Surgery
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21
Q

Lifestyle modifications

A

-weight loss
-sleep w head elevated
-avoid late meals
-avoid triggers
-portion control
-exercise

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22
Q

Treat GERD OTC when

A

-no alarm symptoms
-mild-moderate
-new onset
-identifiable triggers minimized

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23
Q

When to refer GERD

A

-alarm symptoms
-OTC trial for 14 days w no relief

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24
Q

Antacids timing

A

-onset 5 min
-works for 30-60 min
-neutralize acid

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25
Q

Antacid side effects

A

-nausea, vomiting, flatulence
-mg: diarrhea
-Ca and Al: constipation

26
Q

Antacid drug interaction

A

-tetracycline
-fluoroquinolones
-levothyroxine
-digoxin
-azole antifungals
-steroids
-iron
-HIV medications

-takes meds 2 hours before or after antacids

27
Q

Antacid drugs

A

-Tums (calcium carb)
-Milk of Magnesia (mg hydroxide)
-Maalox (al + mg +/- simethicone)
-Gaviscon (al + mg + alginate)
-Rolaids (Ca+Mg)
-Alkaseltzer GAS(Ca + simethicone)
-alkaseltzer (sodium bicarbonate + aspirin + citric acid)
-pepto-bismol (bismuth subsalicylate)
-Gas-X (simethicone)

28
Q

Tums doing

A

-2-4 tablets PRN upto QID
-max 16/day

29
Q

Milk of Magnesia dosing

A

-5-15 mL PRN upto QID
-max 60mL/day

30
Q

Maalox dosing

A

-10-20mL PRN or at meals and bedtime upto QID
-max 80mL/day

31
Q

Gaviscon dosing

A

-2-4 tablets or 10-20mL at meals and bedtime QID
-max 16/day

32
Q

H2RA info

A

-reversible inhibition of H2 in parietal cells
-onset 60 min
-last 4-6 hours

33
Q

H2RA drugs

A

-Famotidine (Pepcid, Zantac)
-Cimetidine (Tagamet)

34
Q

Famotidine dosing

A

-OTC: 10-20mg BID max 40
-rx: 10mg BID pRN 10-60 min before meals
-inc dose to 20mg BID for 2 weeks if no improvement after 2-4 weeks
-if symptoms persist consider PPI
-renal adjustment! give 50% of dose if CrCl is UNDER 50ml/min

35
Q

Cimetidine (Tagamet) dosing

A

-OTC and RX: 200mg qd up to 30 min before meals max 400
-only reduce dose in severe kidney impairment

36
Q

Cimetidine (tagamet) interactions

A

-many drug-drug interactions via CYP1A2, 2C9, 2D6, 3A4

37
Q

H2RA side effects

A

-headache
-dizziness/fatigue
-constipation OR diarrhea
-somnolence/confusion
-agitation
-B12 deficicency

38
Q

H2RA clinical pearls

A

-AVOID in pt at risk of delirium
-use alone or in combo w other classes to treat mild-moderate GERD
-all H2RAs are equally efficacious
-not as effective as PPIs

39
Q

PPIs info

A

-irreversible inhibition of H/K ATPase
-onset 2-3 hours
-lasts 24 hours

40
Q

PPI drugs

A

-Omeprazole
-Pantoprazole
-Esomeprazole
-Lansoprazole
-Dexlansoprazole
-Rabeprazole

41
Q

Omeprazole (prilosec)

A

-OTC: 20mg qd for 14 days
-Rx: 10-40mg qd
-no renal dose adjustments
-take 30-60min before first meal
-metabolized by CYP2C19

42
Q

Pantoprazole (protonix)

A

-PO rx: 20-40mg qd
-IV rx: 40 mg qd
-no renal adjustment
-admin 60 minutes before first meal of the day

43
Q

Esomeprazole

A

-OTC: 20mg qd for 14 days repeat in 4 months
-PO and IV rx: 20-40mg qd
-no renal dose adjustment
-admin 30-60 min before first meal of day
-metabolized by CYP1C19

44
Q

Lansoprazole (Prevacid)

A

-OTC 15 mg qg for 14 days repeat in 4 months
-Rx: 15-30mg qd
-no renal dose adjustments
-orally disintegrating tablet (ODT)
-admin 30-60 min before first meal of day

45
Q

Dexlansoprazole (dexilant)

A

-rx only: no complications at 30 mg but some at 60mg
-60mg qd for 8 weeks then. 30mg indefinitely
-no adjustment
-dual release onset at 1-2 hours and again at 4-5 hours
-can take w/o regard to meals

46
Q

Rabeprazole (Aciphex)

A

-Rx: 10-20mg qd
-no adjustments
-admin 30 min before first meal

47
Q

PPI short term side effects

A

-headache
-dizziness
-diarrhea
-nausea
-ab pain
-infection
-pneumonia

48
Q

Long term side effects of PPIs

A

-hypomagnesemia
-bone density dec/fractures
-vit B12 deficiency
-chronic kidney disease

49
Q

PPI drug interactions

A

-inc effect of methotrexate, phenytoin, warfarin
-dec effect of iron, bisphosphonates, HIV, HCV drugs, clopidogrel

-PPIs are CYP2C19 inhibits (omeprazole and esomeprazole strongest)

50
Q

PPI clinical pearls

A

-tx should not last more than 8 weeks on Rx and 14 days on OTC
-max therapy by inc dose, freq, or switching
-Beer’s criteria
-recommended taper after long term therapy

51
Q

Promotility agents

A

-metoclopramide
-bethanechol
-may be useful as adjunct therapy if no known motility defect
-agents are NOT as effective as acid suppressino therapy and have undesirable side effects

52
Q

Mucosal protectant (sucralfate)

A

-limit use in tx of GERD but could manage radiation esophagitis and nonacid reflux GERD

53
Q

Combination therapies for GERD

A

-Antacids + H2RAs
-PPIs + H2RAs

54
Q

Antacid + H2RA combo

A

-may be helpful for heartburn after meals
-PEPCID AC (famotidine + ca carbonate + magnesium)

55
Q

PPIs + H2RAs

A

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

56
Q

Surgical management of GERD

A

-Antireflux surgery
-reinforces lower esophageal sphincter
-reduces regurgitation and acid back-flow

57
Q

GERD treatment in pregnancy

A
  1. Lifestyle
  2. Antacids w/o aspirin
  3. H2RAs
  4. PPis only if severe
58
Q

GERD symptoms in infants and children

A

-refusing to eat
-wheezing, cough
-dental erosion
-recurrent regurgitation
-irritability

59
Q

GERD alarm symptoms in kids

A

-weight loss
-fever
-seizure
-persistent vomiting and diarrhea

60
Q

Non-pharm options for GERD in kids

A

-thickening formula/foods
-dec volume of intake
-milk free
-positioning therapy

61
Q

Pediatric treatment of GERD

A

-PPIs and H2RAs for 4-8 weeks for DIAGNOSED gerd
-Antacids not chronically and dont use Al or bismuth subsalicylate antacids in kids under 12
-simethicone and probiotics
-ginger, chamomile, peppermint

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