Self Care: GI Part 1 = Heartburn + Dyspepsia + Gas

How should you go about recommeding a patient a medication OTC for heartburn / dyspepsia / Gas?

1. check their primary problems

2. check for any EXCLUSIONS to self care

3. check for therapetic options

4. optimal therapy

5. education of treatment

Patient Case

Are heartburn and dyspepsia COMMON symptoms of the upper GI?
Are they frequently treated with OTC medications?

Who are often the first healthcare providers consulted about treatment?

yes they are common

yes commonly treated w/ OTC medications

first providors = pharmacists

Heartburn:

Burning sensation rising from the abdomen that can radiate to the _______

• how long after eating does it occur?

What is it often described as?

• _______ taste ot _______ in mouth

>60 million american experience hearburn at least once a MONTH!

• radiate UP to neck

• 1-2 hours after eating

• often described as ACID REGURGITATION

  • acid return up the esophagus

Dyspepsia:

• ________with symtpoms such as

  • upper abdominal pain and/or _________

  • painful ________ after eating

  • ______, _______, nausea, vomitting

• How long after eating does it occur?

• 20-40% of American adults report symptoms each year

indigestion

• burning

• painful fullness after eating

• bloating, belching

• minutes to 3 hours after a meal

IN GENERAL OTC medications should NOT be taken for more than _____ ________ without phycian supervision

Can GERD or peptic ulcer disease be treated safely without phsyciian supervision?

DONT be on OTC med for more than 2 weeks

NO

Lower Esophageal Sphincter (LES):

• ______ state prevents reflux from stomach

• ______state allows passage of food into stomach

Esophageal _______ and ________ limits the contraction time with fluid

Esophageal ______ defence contains _____ and _______ used as a defense against acidic contents

Gastric Emptying: gastric contents move into _______ __________ maintaining normal gastric volume in the stomach

• constricted = prevent reflux

• relaxed= allow passage

• clearance and peristasis limits contraction time

• mucous = mucus + bicarbonate

• gastric emptying —> movement into small intestine

Pathophysiology of HEARTBURN:

1. reflux of acidic gastric contants into _________

2. _______ __________ _________ stimulation

3. heartburn

prolonged _______ exposure results in ______ _______ damage (lead to stictures)

• may occur from ________, ____________, or ____________

heartburn can be accompanied by spontanious transient ________ RELAXATIONS

(belching, coughing, vomiting)

1. esophagous

2. esophageal mucosal chemoreceptor

prolonged reflux exposure —→ esophageal LINING damage

• may occur from OVEREATING, LYING DOWN AFTER EATING, DELAYED GASTRIC EMPTYING

transient relaxations

What are some foods that can cause heartburn and dyspepsia?

• fatty or spicy foods

• chocolate

• alcohol

• carbonated or cafeinated drinks

• citrus

• mint

• tomatoes

What are some lifestyle habits that can cause heartburn and dyspepsia?

• exersizing

• smoking

• obesity

• stress

• anxiety

• subpine body position (lying down on back)

What are some conditions that can cause heartburn and dyspepsia?

• motility disorders (achalasia, gastroporesis, IBS)

• GERD + PUD

• Pregnancy

what are some medications that cause heartburn and dyspepsia?

• anticholinergics

• asprin/ NSAIDs

• bisphosphonates

• Calcium Channel Blockers

• Estrogen + Progestins

• Iron

What would give a patient who has

• MILD/ INfrequent symptoms

• do NOT interfere with normal activities

Antacids or H2RAs (-tidines) AS NEEDED

What would give a patient who has

• MODERATE / INfrequent symptoms

• INTERFERES w/ normal activities

H2RAs

What would give a patient who has

• FREQUENT symptoms

• occuring 2+ days a week

PPIs

Who should NOT get an OTC medication for their heartburn/ dyspepsia?

• adults older than ______ with new onset dyspepsia (could be malignancy)

• children less than ____ years old

• Can you take while pregnant?

• adults older than 45

• 12 or less

• CANNOT take while pregnant

If a patient is expereincing which symptoms should you NOT give them OTC medications for their heartburn/ dyspepsia?

• symptoms last longer than >3 months

• frequent symptoms for MORE than 2 weeks WHILE on OTC meds

• SEVERE heartburn/ dyspepsia

• nocturnal heartburn

• chest PAIN

• dyphagia (difficulty swallowing)

• CHRONIC horseness, wheezing, coughing, choking

• CONTINUOUS nausea/vomitting, diarrhea

• black tarry stools or vomitting blood

• unexplained weight loss

What are some alarm symtpoms of heartburn?

REFER TO PHSYICIAN - UNDERLYING ISSUE

• vomitting

• odynophagia (painful swallowing)

• dysphagia (inability to swallow)

• GI bleeding

• Unexplained weight loss

hat are some alarm symtpoms of dyspepsia?

REFER TO PHSYICIAN - UNDERLYING ISSUE

• anemia

• adults older than 45 with new onset symtoms

• dysphagia (inability to swallow)

• GI bleeding

• Unexplained weight loss

for those who ARE candidates for self- treatment what are some options if they have

• MILD

• infrequent

• EPISODIC symtpoms

• Antacids

• Low- Dose H2RAs (10-20mg)

for those who ARE candidates for self- treatment what are some options if they have

• MODERATE

• infrequent

• EPISODIC symtpoms

• antacids

• high dose H2RAs (40mg)

for those who ARE candidates for self- treatment what are some options if they have

• FREQUENT symptoms (2+ days a week)

PPIs

What are some lifestyle modifications you can give somone with heartburn/ dyspepsia?

• Track food, beverage, and activity triggers via diary

• Avoid eating LARGE meals

• Weight loss if overweight/obese

• Stop or reduce cigarette + alcohol + caffeien

• Symptoms + proper admin of medication

○ Discontinue offending agent and recommend more tolerable alternative

• For nocturnal symptoms —> avoid lying down for at least 3 hours after eating

What are the OTC medications for Heartburn/ Dyspepsia?

1. PPIs (frequent)

2. H2RAs (low dose if mild-infrequent - high dose if mod-infrequent)

3. Antacids (if mild-infrequent or mod-infrequent)

What are some OTC antacids that are available?

• sodium bicarbonate

• calcium carbonate

• magnesium hydroxide or carbonate

• aluminum-containing products

Antacids:

Do they provide IMMEDIATE relief?

How long does the relief last?

Does taking antacids AFTER eating increase the duration of their effect?

What is MOA of antacids?

Neutralize excess gastric acid —> inhibit pepsin —> INCREASE LES tone

Cytoprotective effects: stimulate mucus and bicarbonate secretion + bind bile salts

What are some combination products with antacids?

simethicone

alginic acid

Why is simethicone included in some antacid products?

What are some examples?

simethicone helps with gas — decreases surface tensin of gas bubbles in stomach

examples: mylanta (aluminum/magnesium hydroxide + simethicone)

Why is alginic acid included in some antacid products?

What are some examples?

• provides better symtpomic releif as combo

• reacts w/ sodium bicarbonate in saliva to form viscous solution that floats on surface of gastric contents (raft) —> protects against esophageal irritation

example = Gaviscon Extra Stength Liquid

What are adverse effects of the following antacids?

• sodium bicarbonate

• calcium carbonate

• sodium bicarbonate

  • sodium overload —> fluid retention —> weight gain

  • metabolic alkalosis

  • belching + flatulence

  • milk-alkali syndrome

• calcium carbonate

  • hypercalcemia (only 10% absorbed systemically)

  • acid REBOUND due to gastrin release by calcium

  • milk-alkali syndrome

What are adverse effects of the following antacids?

• aluminum salts

• magnesium salts

ammonia salts =

• hypERalluminumia

• hypOphosphatemia (aluminum binds to phosphate)

• constipation

magnesium salts (AVOID in CrCl < 30)=

• hypERmagesemia

• osmotic diarrhea due to insoluble salts

Antacids decrease the absorption of the following drugs due to divalent/trivalent cations binding in the gut?

• fluroquinolones

• azithromycin

• tetracyclines

• levothyroxine

FAT - L (makes divalent trivalent)

Antacids would decrease the absorption of the following drugs due to increased pH decreasing the disentegration and dissolution of them?

Ketoconazole

Itraconazole

Iron

Atazanivir

KIIA (needs an acidic environment)

How would enteric coatred medications be effected by concurrent antacids?

increased pH due to antacids would lead to EALIER degredation and decoating of the drug

Which medications should you seperate the doses by at least TWO hours then take antacids?

• FAT- L (fluroquinolones, azithromycin, tetracyclines, levothryoixines)

• KIIA (ketoconazole, itraconazle, iron, atazanavir)

• enteric coated medications

Antacids should be AVOIDED or heavily monitored if a patient is also taking ______ or _________. Why?

quinidine + salicylate

increased urinary pH leads to DECREASED in quinidine excretion (toxic levels)

and INCREASE in salicylate renal exretion (innefective levels)

What are some risks with antacid-asprin combination products?

Which patients have the greatest risk?

• serious bleeding risk

most vulnerable patients

• 60+

• history of stomach ulcers or bleedings

• on anticogulant, systemic steroids, NSAIDs

• 3+ alcoholic drinks a day

• Alka Seltzer

• Alternagel Liquid

• Gaviscon Extra Strength Liquid (alginic acid+ antacid)

• Gelusil Tablets

• Maalox Liquid

• Mylanta Maximum Strength (simethicone + antacid)

• Pepto Bismol

• Phillips Milk of Magnesia

• Rolaids

• Tums

The following are all examples of what?

antacids

H2RAs:

• when would you use them?

• What is their moa?

• Can they be used for both fasting and ncotornal symtoms?

• infrequent MILD or MOD symptoms of heartburn/dyspepsia

• inhibit H2 —> reduce gastric acid secretion (REGARDLESS OF FOOD)

• YES

H2RAs

How long does it take to feel symptom relief?

How long is its duration of action?

When should you take them in terms of timing with food?

Why is it preffered to take H2RAs as needed instead of daily?

• 30 minutes to feel effects

• BUT duration is long (4-12 hours)

• 30min - 1 hour before a meal or exersize OR once you feel symptoms

• Tachyphylaxis (toelrance) may develop after 7 to 14 days of daily dosing

What are some side effects of H2RAs?

Do you have to adjust renally?

Common

○ Headache, dizziness, drowsiness

○ Diarrhea + Constipation

Rare

○ Confusion, hallucinations, cognitive impairment

• Anemia, leukopenia, thrombocytopenia

○Elevated liver enzymes

○ Impotence, gynecomastia (cimetidine only)

YES RENAL ADJUSTMENTS

The following are examples of what class?

• Tagamet HB (cimetidine)

• Pepcid AC (famotidine)

• Zantac 360 (famotidine)

• Pepcid Complete (famotidine, calcium carbonate,magnesium hydroxide)

• Ranitidine

H2RAs

Which medication was taken off of the market in 2020

Is it used now?

Rantidine

it is NOW reformulated (without NMDA impurtity) and used as of 11/25

What medication does CIMETIDINE (H2RA) decrease the tubular secretion of?

Should you time them apart OR AVOID all together?

procainamide

avoid all together

H2RAs decrease the disentegration and dissolutoon of which drugs, due to their effect of increasing the pH?

Do you have to completely avoid these drugs?

Ketokonazole

Itraconazole
Iron
Atazanavir

Calcium Carbonate (use calcium CITRATE instead of calcium carbonate)

can monitor IF needed

Cimetidine cannot be taken with which. medications due to the inhibition of

• CYP 450 (1A2, 2C19) + to a lesser extent (2D6 + 3A4)

Should you space out these meds or avoid altogether?

Phenytoin

Warfarin

Citalopram

Clopidogrel

Amiodarone

Nifedipine

Theophylline

Tricyclic Antidepressants

Phenytoin and Warfarin CCANTT take cimetidine

PPIs:

• can PPIs be used for immediate relief or occasional use?

• What is its MOA?

• when should you take them in consideration with meals

• are they more or less potent than H2RAs , which has longer onset?

• SHOULD ONLY SELF-TREAT FOR ____ WEEKS —> If longer see doctor

• NOT used for immediate relief or occasional use

• irriversible H+/K+/ ATPase (proton pump) inhibitor

• best taken 30-60 minutes BEFORE meal

• MORE potnent than H2RAs takes 1-3 hours to work BUT lasts 12-24 hours (longer than H2RAs)

dont treat more than 2 weeks

What are some adverse effects of PPIs?

Common

○ Headache, dizziness

○ Diarrhea or vomiting

○ Abdominal pain

● Rare

○ Acute interstitial nephritis

○ Skin rash

○ Anemia, neutropenia, thrombocytopenia

○ Hepatotoxicity

○ Peripheral neuropathy

What are some adverse effects with LONG TERM use?

• demenita

• chronic kidney disease

• bone fracture

• c.diff infection

• community aquired pneumonia

• hypOmagnesemia

PPIs decrease the disentegration and dissolutoon of which drugs, due to their effect of increasing the pH

Do you have to completely avoid these drugs?

Ketokonazole

Itraconazole
Iron
Atazanavir

Calcium Carbonate (use calcium CITRATE instead of calcium carbonate)

can monitor IF needed

Do not give a patient PPIS IF they are on which medications due to CYP450 inhibition leading to increases in their serum concentrations?

Warfarin

Mycophenolate mofetil

cilostazol

diazepam

tacrolimus

WM CDT

Inhibition of renal H+-K+ ATPase pump leads to reduction of __________ elimination. SO AVOID this medication in high doses (should be able to take with lower weekly doses)

methotrexate (MTX)

ESOMEPRAZOLE and OMEPRAZOLE inhibit CYP2C19 which prevents _______ from being converted to its active form which is why you should AVOID concurrent use

clopidrogrel

What is BISMIUTH SUBSYLICYLATE indicated for?

What is its moa?

• heartburn (not sure of mechanism)

• upset stomach (topical effect)

• indigestion

• nausea/ diarhea

MOA:

• may have anti-secretory effects

• binds to bacterial toxins in GI —> supress growth of H.Pylori

Avoid bismuth subsalicylate if you are

• ___________ sensitive (including aspirin)

• have _________ risk

salicylate sensitive

bleeding risk

Warnings/ Drug Interactions of Bismuth Subsalicylate:

• Avoid in children with recent ______ illness, ________, or ______ DUE TO RISK OF _______ SYNDROME

• can you take while pregnant?

• icnreased bleeding risk when taken with _______ and other _____ ________

• increased _______ riusk with oral _________ agents

• avoid in children w/ viral, chickenpox, influenza due to risk of REYES SYNDROME

• NOT recommended while pregnant

• increased bleeding risk with warfarin, aspirin, or other blood thinners

• hypoglycemia risk with antihyperglycemic agents

What is the max dose for bismuth subsalyclate?

• 8 doses per day = max

• Dose = 262-525 mg every 30-60 minutes as needed

What are some side-effects of busmuth subsalicylate?

• Constipation

• Darkening of tongue and stool

● Bismuth toxicity

○ Headache, confusion, ataxia, seizures

● Salicylate toxicity

○ Tinnitus (dose-dependent)

Which populations should you be extra careful when recommending OTC meds for heartburn and dyspepsia?

• elderly (could be underlying disease)

• children 2-12 (CAN use calcium carbonate-containing antacids; track calcium intake)

• pregnant women (aluminum-, calcium-, magnesium-containing antacids are safe + cimetidine + famotidine)

SUMMARY:

• what is used to treat dyspepsia and episodic heartburn?

• what is used to treat frequent heartburn symptoms?

• Antacids + H2RAs

• PPIs

what are the common causes of dyspepsia?

What about heartburn?

dyspepsia:

• PUD

• GERD

• Gastric cancer

heartburn:

• GERD

What is intestinal gas caused by?

What are some side effects you’d see becauase of it?

air in the digestive system

• belching, burbing

• bloating (tension in abdominal area)

• flatulence (14 times per day in HEALTHY person)

• gas pains, cramps

• less common = nausea, dyspepsia, indigesion

1 in ____ americans experience bloating

Do a majority get medical treatment otc?

Who is more likely to get bloating?

1 in 7 americans
NO only 20.8% get treatment

women, less than 60, IBS, chronic constipation, ulcerative colitis

Which gasses are in the intestine normally?

What is the normal amount in mL during fasting and postprandial states?

• Nitrogen (N2)

• Oxygen (O2)

• Hydrogen (H2)

• Carbon Dioxide (CO2)

• Mathane (CH4)

200mL = normal

Where do we get our intestinal gases from? (O2, H2, N2, CO2, CH4)

bacterial fermentation of dietary carbohydrates in the colon

What increases intestinal gas?

• excessive aerophagia (swallowing air) — eating quickly, carbonated drinks, anxiety, chewing gum, smoking

• Intraluminal production due to malabsorbed nutrients

• decreased gas absorption due to obstruction

• expansion of intraluminal gas from atmospheric pressure. changes

What are some FOODS that cause gassiness?

vegetables: onion, celery, carrots, brussel sprouts, cabbage, legumes

fruits: bananas, raisins, apricots

carbonated drinks

dailry products

carbohydrates: whole grains + brown rice

What are some lifestyle habits that lead to intestinal gas?

• smoking

• gulping food

• chewing gum

• high fiber diet

what are some medications that can lead to intestinal gassiness?

• Antibiotics

• Narcotics

• α-glucosidase inhibitors: acarbose + miglitol

• Cholestyramine

• Psyllium

What are some conditions that can cause increased intestinal gassiness?

• Carbohydrate malabsorption: lactase deficiency

• Pancreatic insufficiency

• Irritable bowel syndrome (IBS)

• Celiac disease: gluten protein sensitivity

• Gastroparesis

what are some medications that are used in patients with intestinal gas?

smithicone = safe for children + pregnant women

digestive enzymes (lactase + a-galactosidase) = PREVENTION ONLY

can you use activated charcoal for intestinal gas?

NO has not been proven to be effective

who should NOT be treating their gas over the counter?

• onset if older than 40

• PERSIST several days + several times per month

• SEVERE debilitating symptoms

• increased symptom severity or frquency

• sudden change in location of abdnominal pain

• severe + persisent diarhea or constipation

• GI bleeding

• unintended weight loss

• frequent NOCTORNAL symptoms

• fatigue

is the goal of intestinal gas treatemnt to completely eliminate all gas?

NO that snot realistic AND we need gas for GI tract function

What are some non-pharmacological methods you can use for intestinal gas?

Smoking cessation

Eat and drink slowly

Avoid chewing gum and gas producing foods

Do not lie down immediately after eating

● Lactose intolerance —> avoid milk and dairy products

• Use lactase replacement and substitutes

● Consider probiotic dietary supplements

Simethicone (Mylicon):

_________ agent to relieve gas

• reduces the ___________ ________ of gas bubbles in _______ of GI tract

• gas bubbles are broken or consolidated into ___________ making elimination easier

• is simethicone absorbed from the GI tract? Do you experience any SYSTEMIC adverse effects?

• who is simethicone treamtent CONTRAINDICATED in?

defoaming

• Reduces the surface tension of a gas bubble in MUCUS

• bubbles are broken or form one big bubble that makes elimination easier

• NOT absorbed from GI tract —> NO systemic effect

• CONTRAINDICATED if you suspect intestinal obstruction or preforation

What is the max dose of simethicone?

max/ day = 500mg

dosage = 40-125 mg PRN after meals and at bedtime

Lactase Replacement (Lactase):

• indicated for ________ _________

  • breaks down _________ into _______ and _________

• when do you take it?

• what are some dosage forms it comes in?

• lactose intolerance

• breaks down lactose —> glucose + galactose

• must be taken WITH first bite of dairy product

• drops, tablets, capsules

a-D-galactosidase (Beano):

• promotes _______

• is it used as treamtent or prevention?

• hydrolizes ____________into digestible ________ which are then metabolized by ________ ____________

• is it considered a dieatary supplemnet?

• is it regarded safe by the fda?

digestion

used as PREVENTION

hydrolyzes oligosaccharides into digestable sugars —> metabolized by bacteria in colon

• it IS considered a supplement

• IS regarded safe by FDA

Which patients should AVOID a-D-galactosidase (Beano)?

• if allergic to mold (it is an enzyme that is derived from Aspergillus)

• if patient has galactosemia

What are some oligosaccharide containing foods that would be hydrolyzed into digestible sugars to be further broken down by colonic bacteria by a-D-galactosidase?

• beets

• brocolli

• brussel sprouts

• cabbage

• barley

• wheat

• soy

• blueberry

• bananas

what would you recommend for this patient?

Do they have any exclusions to self-treatment?

Frequent heartburn —> PPI

Flatulence —> simethicone

NO exclusions

tell them that carbonated drinks and lying down right after eating could be a lifestyle change he can consider

What would you treat her with?

We should not treat her over the counter bc/ she is experiening onset after the age of 45 (it could be an underlying cause) + bc/ she has nocturnal heartburn