Esomeprozole
AE / Counsult
Nexium
Take 60 min prior to eating
May be taken WITH Antacids
<18 y/o PPI’s
Headache / Diarrhea
Constipation / Flatulence
Nausea / Ab pain / dry mouth
Pepcid AC
DOSE / Indication
Famotadine
OG / Max = 10mg / 20mg
H2RA for Heartburn
1 dose (10mg) taken with water
MAX 2 doses in 24 hour period
Mintox / Mylanta
AE / Consult
Aluminum hydroxide / MgOH / Simethicone
Diarrhea / Constipation
<14 days
FULL GLASS OF WATER
Pathophysiology of Heartburn
-
Esophogeal epithelium nerve Stimulation
- SPICY food
- Refluxate
- Impaired Esophageal clearing mechanisms
- Pressure gradient between LES / Stomach is less than normal or absent:
- REDUCED SPINCTER TONE
Pepcid Complete
CIP / DI
Famotadine + Calcium Carbonate + MgOH
SAME AS PEPCID
Hypersensitive to famotadine
- Impared renal fxn*
- Caution with Pregnancy / Lac*
PREGNANCY CAT B
WARFARIN
Heartburn Epidemiology
Men = Women
No Difference in age groups
Increase in Pregnancy
Medications that cause a
DIRECT IRRITANT EFFECT
Antibiotics
ASA / NSAIDs
Bisphonates
IRON / Potassium supplements
Quinidine / Zidovudine
Tums
AE / Consult
Calcium Carbonate
Bloating / Flatulance
<6000mg for 14 days
Take chewable tabs with FULL GLASS OF WATER
Medications that
REDUCE Spincter Tone
Alpha - agonist / blockers
Anticholinergics
Barbs / BZD’s / TCA’s
CCB’s / Nitrates / Theophylline
Estrogen / Progestrone
Dopamine / Phentolamine
Omeprazole Mg
Dose / Indication
Prilosec OTC
1Tab (20mg) qd b4 breakfast
for 14 consecutive days
Corse may be repeated once every 4 months
May take up to 1-4 days for full effect
Do NOT CRUSH OR CHEW TABS
Tums
CIP / DI
Calcium Carbonate
DNU <2 yo
max dose is 6000mg
Tetracyclines / Penicilin
Quinalone AB’s / Digoxin
Enteric coated drugs
Heartburn ALARM Symptoms
- Frequent and >3 MONTHS
- Dysphagia / odynophagia
- Unexplained weight loss
- N/V/D
- Chronic hoarseness / wheezing / coughing / choking
-
Chest Pain w/
- sweating / pain radiating to shoulder-arm-neck-jaw
- Shortness of breath = SOB
- Evidence of GI BLEEDING
- Personal / H/o ULCERS
Zantac OTC
MAX Dose
Ranitidine HCL
<2 tabs in 24 hours
(2 - 75mg tablets = 150mg /day)
do not use consecutive days for
>14 days!
Esomeprazole MgH3
Dose / Indication
Nexium 24hr
PPI for heartburn
20mg qd for 14days
May take up to 3 days to be effective
S/S of Heartburn
Burning Sensation Substernal area
Radiates towards neck / throat
Can occur within 2 hours of eating
Bending over / Lying Down / Sleeping
Zantac OTC
DOSE / Indication
Ranitidine HCL
Norm / MAX = 75mg / 150mg
H2RA for Heartburn
1 tab (75mg) taken with water
MAX 2 doses in 24 hour period
<14 days use
Etiology (Causes) of Heartburn
- Certain food / Drinks / Smoking
- Regular use of ASA / NSAIDs
- Stress / Obesity
- PREGNANCY
- Diseases / medication
- Certain types of exercise
Exclusions for Self-Treatment
Heartburn
- PREGNANCY** / **NURSING
- Continuing heartburn while taking recommended doses / durations
- Children <12 y/o
- Antacids & H2RAs
- Children <12 y/o
-
Children <18 y/o
- PPI’s
Pepcid AC
ADR / Consult
Famotadine
Headache / Dizziness / Constipation / Diarrhea
May be taken w/ antacids (for acute pain)
Plenty of water!
Avoid Alcohol
<2 dose (max) for <2 weeks
Esomeprozole
CI / P / DI
Nexium
-
DNU - pain swollowing / vomiting blood
- bloody or black stools
- Beware of patients with >3 months of heartburn w/:
- frequent wheezing / weight loss / stomach pain
- nausea + vomiting
- frequent wheezing / weight loss / stomach pain
- Steven-Johnson Syndrome
- DI’s:
- Ketoconozole / Digoxin / B12 / Ampicillin
- Voriconozole / Cilostozole
- Clopidogrel / Diazepam
Omeprazole
ADR + Consult
Prilosec
Back Pain / Cough / Constipation
Rash / Dizziness
PPI >18yr
Take 30 min prior to eating, may be taken w/ antacids
DNU for >14 days every 4 months
See MD if >3mo
lightheadedness + sweat + dizziness + chest/shoulder pain
Frequent wheezing / pain in arm or neck
Classification and Treatment of
FREQUENT Heartburn
- 2+ days/ week
- GERD if > 3 mo
- Recommend:
-
PPIs (slowest onset / longest duration)
- 14 days, repeat every 4 months
-
PPIs (slowest onset / longest duration)
Tums
MAX dose
Calcium Carbonate
Max 6000mg / day
12 regular
8 extra
6 max
Zantac
CIP / DI
Ranitidine
- Impared renal fxn / hepatic*
- Caution with Pregnancy / Lac*
PREGNANCY CAT C
(cat c , pepcid is cat b)
WARFARIN / Lidocaine
DIazepam / Nifedipine / TCA
Classification and Treatment of
Mild / Infrequent Heartburn
- Can be Episodic
- Associated with diet / Lifestyle
- Recommend:
- Antiacids (FAST ONSET / short duration)
- lower dose H2RAs (slow onset / LONG DURATION)
Pepcid AC
CIP / DI
Famotadine
Hypersensitive to famotadine
- Impared renal fxn*
- Caution with Pregnancy / Lac*
PREGNANCY CAT B
WARFARIN
Zantac
ADR / Consult
Ranitidine
Headache / Dizziness / Constipation / Diarrhea
- +Abdominal Pain*
- If you have trouble swallowing or persistant ab pain, SEE MD*
Plenty of water!
<2 dose (max) for <14 days
Classification and Treatment of
Moderate/ Infrequent Heartburn
- Can be Episodic
- Associated with diet / Lifestyle
- Recommend:
- Antiacids (FAST ONSET / short duration)
- HIGHER dose H2RAs (slow onset / LONG DURATION)
Lansoprazole
CI / P / DI
Prevacid
Hypersensitivity to components
Tacrolimus / Theophylline
Ketoconazole / ampicillin
Iron salts / Digoxin
Lansoprazole
ADR / Consultation
Prevacid
Diarrhea / Ab Pain / Nausea / Headache
>18yo for PPI’s
Take 30 min prior to eating
Can be taken WITH ANTACIDS
See MD if >3 months
DNU if trouble swallowing food / vomit blood
Black + Bloody stools
H2RAs
Onset / Indications
Pepcid - AC (famotidine) / Zantac (ranitidine)
Binds competitively/rev to H2 receptors of gastric parietal cells
INCREASES gastric pH
Onset = 30-45 min (slow)
Duration = 4-10 hours (long)
Preventative** med: take **15-60min before known irritating foods
TOLERANCE CAN OCCUR
Lansoprazole
Dose / Indication
Prevacid
PPI for frequent heartburn (2+ days in a week, >18yo)
1 Cap (15mg) 30min b4 BF
q14 consecutive days
14 day course may be repeated once every 4 months
may take 1-4 days for full effect
DO NOT CRUSH OR CHEW TABS
Non-Pharmacologic Treatment of Heartburn
-
Avoid:
- Foods / Activities / Medications (that trigger symptoms)
- Large meals / Smoking
- Lose Weight if overweight
- Wear loose-fitting clothes
- Elevate head of bed
- AVOID LYING DOWN WITHIN 3 HOURS OF A MEAL
EX-ST For Heartburn in Children
Antacids & H2RAs
<12 y/o
Mintox / Mylanta
Dose / Indication
Aluminum hydroxide / MgOH / Simethicone
200mg / 200mg / 25mg
Liquid is 20mg simethicone + others / 5mL
Antacid for heartburn
2-4 doses QID after meals
& at bedtime
Foods that REDUCE SPHINCTER TONE
Alcohol / Soda
Garlic / Onions
Foods high in SUGAR / FAT
Chocolate / Caffeine
PEPPERMINT / SPEARMENT
Pharmacologic Treatment of
Heartburn
Antacids
Histamine 2 Receptor Agonist (H2RA)
PPI
EX-ST For Heartburn in Children
PPIs
<18 y/o
General Counseling for
H2RAs
- ADRs
-
Diarrhea / Constipation / Headache
- generally WELL TOLERATED
-
Diarrhea / Constipation / Headache
- DI’s
-
Cimetidine is cyp inhibitor
- not used anymore
-
Reduced absorption of: (due to low acid environment)
- Ketoconazole
- Itraconazole
- IRON
-
Cimetidine is cyp inhibitor
Foods that cause a
DIRECT IRRITANT EFFECT
Citrus
Coffee
Spicy foods
Tomato Products
PPIs
Onset / Indications
Prilosec / Prevacid / Nexium
Omeprazole / Lansoprazole/ Pantoprazole
FOR PREVENTATIVE TREATMENT
onset is 2-3 hours (slow onset)
Complete relief in 1-4 days
Binds irreversibly to proton pump in gastric parietal cells
inhibits secretion of gastric acid
Classification and Treatment of
Mild / Infrequent Heartburn
- Can be Episodic
- Associated with diet / Lifestyle
- Recommend:
- Antiacids (FAST ONSET / short duration)
- lower dose H2RAs (slow onset / LONG DURATION)
H2RA + Antacid
Pepcid / Tums COMPLETE
Combines FAST ONSET of antiacid (<5 min)
with
LONGER DURATION of H2RA (8-10 hrs)
Mintox / Mylanta
CIP / DI
Aluminum hydroxide / MgOH / Simethicone
DNU <2 yo
DNU in renal disease -> HYPER MAGNESEMIA
<14 days
Tetracyclines / Penicilin
Quinalone AB’s / Digoxin
Enteric coated drugs
General Counseling for
ANTACIDS
(Tums / Mylanta)
-
Liquids > Chewable tabs (onset time)
- chewables need to be chewed COMPLETELY
- GLASS OF WATER
- chewables need to be chewed COMPLETELY
- Dosing should NOT be more than 4xDay
- Caution in RENAL impairment
- beware of DI’s
- ADRS:
-
Diarrhea w/ MG or Mg/al products
- (mylanta / mintox)
-
Constipation w/ Ca or Al products
- (tums)
-
Diarrhea w/ MG or Mg/al products
Tums
Dose / Indication
Calcium Carbonate
Reg / Extra / Ultra = 500/750/100mg
Antacid for heartburn
Chew 2-3 tabs
Repeat HOURLY if symptoms occur
Max 6000mg (12 regular strength) in a day
Pepcid Complete
DOSE / Indication
Famotadine + CaCo2 + MgHO
Complete = 10mg / 800mg / 165mg
H2RA for Heartburn / + extra for indigestion
1 dose taken with water
MAX 2 doses in 24 hour period
Pepcid Complete
ADR / Consult
Famotadine + Calcium Carbonate + MgOH
SAME AS PEPCID
Headache / Dizziness / Constipation / Diarrhea
May be taken w/ antacids (for acute pain)
Plenty of water!
Avoid Alcohol
<2 dose (max) for <2 weeks
Omeprazole
CI / P / DI
Prilosec
PREGNANCY CATEGORY C
Gastric carcinoid tumors (long term use)
Diazepam / Phenytoin
Tacrolimus / Warfarin
Ketoconazole / ATAZANAVIR / digoxin
B12 / Ampicillin / IRON
Antacids
Onset / Indications
Tums / Mylanta
Rxn with stomach acid to form SALT
NOT FOR PREVENTION
FAST ONSET (5 minutes)
Duration ranges from:
20 min - 3 hours
(empty - full stomach)