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PHRM 504 > Lecture 13: Heartburn/Dyspepsia > Flashcards

Lecture 13: Heartburn/Dyspepsia Flashcards

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1
Q

Dyspepsia

A

A constellation of upper abdominal symptoms
-Bothersome postprandial fullness, early satiation,
epigastric burning, epigastric pain

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2
Q

Pyrosis

A

“Burning feeling” in stomach or lower chest when

acid comes into contact with esophagus lining

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3
Q

Gastroesophageal Reflux Disorder (GERD)

A

Chronic symptoms occurring ≥ 2 times per week

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4
Q

Peptic Ulcer Disease

A

Erosion in the lining of the gastrointestinal tract (GIT) Gastric or duodenal ulcers

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5
Q

Physiology: Defense Mechanism

A

Anti-reflux barriers
Esophageal acid clearance
Tissue resistance

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6
Q

Antireflux barriers

A

Lower esophageal sphincter (LES)
Relaxes on swallowing: food -> stomach

When you swallow food, the LES relaxes which allows the food to enter the stomach

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7
Q

Esophageal acid clearance

A

Gravity
Peristalsis- involuntary constriction and relaxation of the muscle in the intestines which moves food through the digestive tract

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8
Q

Tissue resistance

A

• Esophageal blood supply maintains
acid-base balance
• Delivers bicarbonate, nutrients, oxygen
• Removes carbon dioxide, hydrogen

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9
Q

Gastroesophageal reflux disease

A

Occurs when esophageal sphincter does not close properly. This allows food or acid reflux to wash back up into your esophagus which causes irritation.
- Some treatments are OTC ad prescription antacid medications, diet and lifestyle changes, and surgery

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10
Q

What cause irritation and injury (symptoms)

A

Excessive reflux of gastric substances and breakdown of defensive mechanisms

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11
Q

Risk factors of heartburn: Food

A

Food such as chocolate, coffee, tea, citrus, tomatoes, garlic, onions, peppers and mint

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12
Q

Risk factors of heartburn: Medications

A

Medications:

  • Anticholinergic
  • Aspirin, NSAIDs
  • Iron
  • Nicotine
  • Alcohol
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13
Q

Risk factors of heartburn: Others

A
  • Alcohol
  • Family history
  • Genetics
  • Obesity
  • Pregnancy
  • Stress
  • Supine body position
  • Tight-fitting clothing
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14
Q

Which of the following is an anticholinergic adverse effect?

a. Bradycardia
b. Diarrhea
c. Dry moth
d. Increased urination

A

c. Dry mouth

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15
Q

Which of the following medications has anticholinergic properties?

a. dextromethorphan
b. diphenhydramine
c. Gaviscon
d. guafenesin

A

b. diphenhydramine

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16
Q

Clinical Presentation: Heartburn

Typical Symptoms

A
  • Pyrosis
  • Belching
  • Hypersalivation
  • Regurgitation
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17
Q

Clinical Presentation: Heartburn

Atypical Symptoms

A
  • Asthmatic symptoms
  • Chest pain
  • Chronic cough
  • Dental erosions
  • Globus sensation
  • Hoarseness
  • Laryngitis
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18
Q

Clinical Presentation: Heartburn

Alarm Symptoms

A
  • Dysphagia
  • GI bleeding
  • Odynophagia
  • Unexplained weight loss
  • Vomiting
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19
Q

Clinical Presentation: Dyspepsia

Typical Symptoms

A
  • Early satiation
  • Epigastric burning
  • Epigastric pain
  • Postprandial fullness
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20
Q

Clinical Presentation: Dyspepsia

Associated Symptoms

A
  • Belching
  • Bloating
  • Nausea
  • Vomiting
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21
Q

Clinical Presentation: Dyspepsia

Alarm Symptoms

A
  • Anemia
  • Blood loss
  • Dysphagia
  • Weight loss
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22
Q

Exclusions to self care: heartburn/ dyspepsia

A
  • Frequent heartburn for ≥ 3 months
  • Heartburn while taking recommended dosages of
    nonprescription H2RAs or PPIs
  • Heartburn that continues after 2 weeks of treatment with a
    nonprescription H2RA or PPI
  • Heartburn and dyspepsia that occur when taking a
    prescription H2RA or PPI
  • Severe heartburn or dyspepsia
  • Nocturnal heartburn ( at night)
  • Difficulty or pain when swallowing solid foods
  • Vomiting up blood or black material or passing black tarry
    stools
  • Chronic hoarseness, wheezing, coughing, or choking
  • Unexplained weight loss
  • Continuous nausea, vomiting, or diarrhea
  • Chest pain accompanied by sweating, pain radiating to
    shoulder, arm, neck, or jaw, and shortness of breath
  • Children < 2 years (for antacids)
  • < 12 years for H2RAs
    -< 18 years for PPIs
  • Adults > 45 years with new-onset dyspepsia
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23
Q

Goals of Self-Treatment

A
  1. Provide complete relief of symptoms.
  2. Reduce recurrence of symptoms.
  3. Prevent and manage unwanted effects of medications
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24
Q

Non-Pharmacologic Therapy

A
  • Avoid trigger foods and beverages
  • Eat ≥ 3 hours before bed/lying down
  • Elevate head of bed
  • Reduce size of meals
  • Smoking cessation
  • Weight loss

These measures should be recommended for ALL patients

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25
Pharmacologic Therapy options
Antacids H2RAs PPIs
26
Antacids taken for
- mild, infrequent, heartburn, dyspepsia | - rapid relief of symptoms
27
H2RAs taken for
- Mild-moderate, episodic heartburn and dyspepsia - More prolonged relief of symptoms - Prevent heartburn and dyspepsia - Give 30 minutes to 1 hour prior to anticipated symptoms
28
PPIs taken for
- Frequent heartburn and dyspepsia ( ≥ 2 days per week) - Nonresponse to H2RAs- symptoms don't go away w H2RAs - Complete relief of symptoms may take several days
29
Antacids options
- Various salts - Aluminum: hydroxide, phosphate - Calcium: carbonate - Magnesium: carbonate, hydroxide, trisilicate - Sodium: bicarbonate
30
Antacids Brand Name
``` Gaviscon Maalox Mylanta Rolaids Tums ```
31
Antacids MOA
Neutralize gastric acid (buffering agents)
32
Antacids PK
Onset: less than 5 min Duration: 20-30 mins (prolonged by food in the stomach)
33
Antacids Contraindications
``` Calcium supplements (sodium bicarbonate) - Hypersensitivity ```
34
Antacids Precautions
``` Renal imparment (for all salt forms) - Risk of fluid overload ( sodium bicarbonate) ```
35
Antacids Adverse effects
Generally well tolerated Aluminum-containing: Constipation Calcium Carbonate/ Sodium Bicarbonate: belching; flatulence Magnesium-containing: Diarrhea
36
Antacids Drug interactions
Fluoroquinolone/tetracycline antibiotics; pH dependent medications
37
Antacids Dosing
- Use product-specific recommendations at onset of symptoms - May repeat in 1-2 hours, if needed - Do not exceed maximum daily dosage
38
Antacids Special Pops
- Breastfeeding: Al, Ca, Mg considered safe - Children: calcium carbonate > 2 years - Pregnancy: Ca, Mg considered safe
39
H2RAs Drugs agents
Cimetidine- Tagamet : 200 mg, MDD: 400mg Famotidine- Pepcid AC: 10-20 mg, MDD 40 mg Ranitidine- Zantac: 75-150 mg, MDD 300mg
40
H2RAs MOA
Inhibit histamine on the histamine type 2 receptor of the parietal cell. This decreases fasting and food-stimulated gastric acid secretion and gastric volume
41
H2RAs PK
Onset: 30-45 minutes Duration: 4-10 hours
42
H2RAs Contraindications
Hypersensitivity
43
H2RAs Precautions
Advanced age; renal impairment
44
H2RAs Adverse Effects
Generally well tolerated Constipation; diarrhea; dizziness; drowsiness; headache Rare, but serious: thrombocytopenia
45
H2RAs Drug Interactions
- pH dependent medications - Cimetidine: inhibits several P450 enzymes resulting in numerous interactions: ex: amiodarone; phenytoin; tricyclic antidepressants; warfarin
46
H2RAs Dosing
- Take by mouth 30-60 minutes prior to foods/beverages that cause heartburn - Limit to no more than 2 doses/day - Preferable to take as needed
47
H2RAs Special pops
- Advanced age/renal impairment: lower doses are recommended - Breastfeeding: famotidine preferred - Children: ≥ 12 years - Pregnancy: compatible
48
H2RAs: Concerns
Nitrosamine impurity – N-nitrosodimethylamine (NDMA) | - Probable human carcinogen
49
Process of removing H2RAs from market
- September 2019: • First voluntary recall of specific lots of product - October 2019 • Food and Drug Administration (FDA) launched investigation • Manufacturers to conduct laboratory testing to examine NDMA levels and send samples to FDA - December 2019: FDA expands testing to ALL lots before available to consumers FDA, 2020. H2RAs: Concerns - April 1st, 2020 • “FDA Requests Removal of All Ranitidine Products (Zantac) from the Market” • ALL prescription and OTC ranitidine drugs • NDMA in some products increases over time and when stored at higher than room temperatures • May result in consumer exposure to unacceptable levels of this impurity
50
PPIs Agents
- Esomeprazole (Nexium 24HR®): 20 mg, MDD 20 mg - Lansoprazole (Prevacid 24HR®): 15 mg, MDD 15 mg - Omeprazole (Prilosec OTC®): 20 mg , MDD 20 mg
51
PPIs PK
Onset: 1-3 hours Duration: 12-24 hours
52
PPIs Contraindications
Hypersensitivity
53
PPIs Precautions
Hepatic impairment ; renal impairment
54
PPIs Adverse Effects
Constipation; diarrhea; headache
55
PPIs Drug Interactions
- pH dependent medications | - CYP2C19 substrates: ex. clopidogrel, phenytoin, warfarin, pH dependent medications
56
PPIs Dosing
- Take by mouth with a glass of water 30 minutes before breakfast - Take daily for 14 days - May be repeated every 4 months
57
PPIs Special Pops
- Breastfeeding and pregnancy: limited data available | - Children: ≥ 18 years
58
PPIs MOA
Binds to and Inhibits hydrogen potassium ATPase (proton pump) which irreversibly blocks gastric acid secretion
59
PPIs Concerns
Chronic acid suppression: • Potential to increase infection risk • Bacterial gastroenteritis, Clostridium difficile, community-acquired pneumonia High-dose, long-term (> 1 year) use can cause: - Increased risk hip, spine, wrist fractures (patients > 50 years) Long-term use can cause - Hypomagnesemia, iron malabsorption, vitamin B12 deficiency • Newer studies: - Associated with risk of dementia - Increased risk of chronic kidney disease (CKD)
60
Bismuth Salicylate Brand Name
Pepto-Bismol®
61
Bismuth Salicylate MOA
Unknown for relief of heartburn
62
Bismuth Salicylate Contraindications
Hypersensitivity
63
Bismuth Salicylate Precautions
Bleeding disorders; children; pregnancy; renal failure
64
Bismuth Salicylate Adverse Effects
Fecal discoloration (gray-black); tongue discoloration (darkening)
65
Bismuth Salicylate Dosing
- 262-525 mg by mouth every 30-60 minutes as needed | - MDD 8 doses (262 mg), 4 doses (525 mg
66
Patient Education for Antacids
- Use for relief of mild, infrequent symptoms | - Take at onset of symptoms
67
Patient Education for H2RAs
- Take at onset of symptoms or 30-60 minutes before symptoms are expected
68
Patient Education for PPIs
- Take with a full glass of water every morning 30 minutes before breakfast for 14 days - Take the full 14-day course of treatment - Do not cut, crush, or chew tablets or capsules
69
Evaluation of Patient Outcomes: Antacids
- Reevaluate if using more than 2x/week or regularly for more than 2 weeks - Frequent users may need a longer-acting product
70
Evaluation of Patient Outcomes: H2RAs
If treatment needed for more than 2 weeks, refer
71
Evaluation of Patient Outcomes: PPIs
- If treatment needed for more than 2 weeks, refer | - If symptoms recur within 4 months, refer

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