General HB Info

hearburn (pyrosis)

burning sensation in stomach/lower chest that extends up to neck, throat, and occasionally back

• one of the most common GI complaints

• HB is one of the main symptoms of GERD

define dyspepsia

symptoms originate in gastroduodenal region → postprandial fullness, early saturation, epigastric pain, and burning

• may also report anorexia, belching, nausea & vomiting, and upper abdominal bloating

3 principles of heartburn meds addressing stomach acids

1. neutralize what’s there → antacids

2. make less of it → H2RAs

3. shut off factory → PPIs

describe pathophysiolgoy of HB

• misfunction of antireflux barriers that keep gastric contents out of esophagus

→ LES = lower esophageal sphincter- stays contracted at rest, relaxes on swallowing; transient LES relaxations = occur w/o swallowing, allowing stomach contents to move back toward esophagus

how might obesity lead to hearburn?

increases intra-abdominal pressure

how does pregnancy increase HB risk?

lowers LES pressure

risk factors that contribute to HB

• decrease in LES pressure → more reflux (fatty foods, chocolate, peppermint, theophylline, morphine, Ca channel blockers, diazepam)

• irritated esophageal mucosa (citrus, tomato, spicy foods)

• relaxed LES and decreases salivation (smoking)

• increase pain perception (anxiety, fear, worry)

• increase in abdominal pressure (bending over, straining to defecate, lifting heavy objects, isometric exercise, obesity)

SCHOLAR-MAC considerations for HB

• episodic/infrequent HB = <2 days/week, mild-moderate

• frequent HB = >2 days/week, if it is persistent (3+ months) → GERD (exclusion)

when to refer HB

• alarm symptoms

• cardiac mimic

• chronic/treatment resistant

• atypical/extraesophageal

alarm symptoms

• trouble swallowing (dysphagia)

• painful swallowing (odynophagia)

• upper GI bleeding

• unexpected weight loss

cardiac mimic

• chest pain w sweating

• SOB

• pain radiating to shoulder/arm/neck/jaw → EMERGENCY

chronic/treatment resistant indications that lead to referral

• symptoms over 3 months

• currently on H2RA or PPI

• symptoms continue after 2 weeks on H2RA/PPI → GERD

atypical/extraesophageal indications for referral

• noncardiac chest pain

• difficulty breathing

• hoarseness

• laryngitis

• chronic cough

• dental erosion

• lump in throat feeling

if you have established self-care candidacy, what should be the first recommendation?

non-drug measures, then OTC

considerations when choosing medication for HB

• frequency, duration, and severity of symptoms

• cost of med

• drug-drug interactions

• adverse effects

• patient preference

***frequency drives choice

what drives OTC selection?

frequency of HB

what is the first line for episodic/infrequent HB?

antacid and/or H2RA

• fast relief → antacid

• lasting/pre-treat → H2RA (prefer famotidine)

• both → antacid + H2RA combo

first line for frequent HB

PPI (take daily)

• take 30 min before breakfast

• 14 day course, don’t repeat more than once every 4 months

• NOT for immediate relief of a single episode

antacids act as ________ in the lower esophagus, stomach, and duodenum

buffering agents

effect of antacids on LES pressure and intragastric pH

moderately increase

why is antacid onset so fast?

the stomach acid is already present for antacids to work on

do liquid or tablet antacids work faster?

liquids— already dissolved

what determines the side effects of an antacid?

the cation— Mg, Al, Ca carbonate, or Na bicarbonate

counseling point if pt is taking levothyroxine and an antacid that contains Ca, Mg, or Al

separate doses by 4 hrs — these antacids bind levothyroxine in the gut and decrease its absorption

what is the purpose of the antacid + alginic acid combination?

forms raft in stomach, blocking acid from rising → more effective together in lowering HB

side effects for antacids containing Mg

diarrhea— Mg is osmotic, pulling H2O into intestine and distending colon

side effect for antacid containing Al

constipation — Al is an insoluble salt, slowing motility

side effect of antacids containing Na carbonate or Na bicarbonate

belching/gas — carbonate reacts with HCl (stomach acid) to release CO2 gas

H2RAs

histamine-2 receptor antagonists

• block histamine at H2 receptor on parietal cell leading to a decrease in both fasting and food-stimulated acid secretion

• turn down acid production

what is the onset time for H2RAs?

30-45 min

how long is the relief in H2RAs?

4-12 hours

what HB OTC class is most effective for fasting and nocturnal symptom?

H2RA

why are H2RAs prn?

tolerance can develop with daily use

what is the preferred H2RA?

famotidine

what is the most potent HB OTC med?

PPI

3 common PPIs

1. omeprazole

2. esomeprazole

3. lansoprazole

how do PPIs work?

irreversibly block the proton pump (final step in acid secretion) leading to a prolonged effect

• only inhibit actively secreting pumps → take 30-60 min before first meal of day

how many proton pumps does each PPI disable?

1

onset of relief for PPI

1-3 hours

when does complete relief occur with PPI? why?

1-4 days

the body replaces the pumps that the PPI blocks, so it takes a while for the PPI to block enough pumps to create relief

what OTC is recommended for frequent HB?

PPI

important counseling point for PPI tablets/capsules

don’t chew/crush— the coating protects the drug from stomach acid

how long can you use PPI?

14 days no more than every 4 months

age requirement for PPI

18 years

age requirement for H2RA

12 yrs

age requirement for antacids

2 years

HB treatment for geriatric

• use Al/Mg antacids sparingly when decreased renal function

• if H2RA, lower dose and avoid cimetidine

• avoid Na bicarbonate if Na-sensitive

• avid H2RA in patient with delirium or risk of delirium, instead use short pPI course

treatment for pediatric HB

• in kids over 2 years with mild, infrequent symptoms use kids Ca carbonate antacids, may be tried daily

• H2RAs may be used if 12 or older

• PPI may be used if over 18

treatment for HB in pregnancy

• start w diet and lifestyle

• antacids are safe within daily limits

• cimetidine and famotidine are compatible with pregnancy

treatment for HB in breastfeeding

• antacids are safe

• cimetidine is compatible

• PPI data is insufficient → DON’T RECOMMEND

self-treat _______ - ________ symptoms only

mild - moderate

when determining best option for pt, screen for ____________

existing prescription

what is the safest HB treatment in renal impairment?

PPI

why do we generally avoid cimetidine?

it inhibits several cytochrome P450 (CYP) enzymes — it has more drug interactions than the other H2RAs, which limits its use

why do we screen for clopidogrel use?

Omeprazole and esomeprazole may inhibit certain CYP2C19 variants, reducing conversion of clopidogrel to its active form and weakening its antiplatelet effect

how do you determine if a pt is having cardiac symptoms or heartburn?

• description of pain— burning = HB

• cardiac symptoms may come on w exertion and resolve w rest; HB will persist

bismuth subsalicylate

pepto-bismol

• indicated for heartburn, upset stomach, indigestion, nausea, and diarrhea (it's believed to act topically on the stomach mucosa)

• warn pt— may turn stool or tongue black

what cation is present in alka seltzer?

sodium bicarbonate

should you ever prescribe an H2RA at the same time as a PPI?

no— n additive impact

what is Maalox made of?

aluminum hydroxide + magnesium hydroxide

what antacid is recommended for 2 yr old?

calcium carbonate (kids)

lifestyle changes for nocturnal HB

• raise head of bed

• leave 2-3 hrs b/w meal and lying down

• sleep on left side (puts LES above stomach acid)

does aluminum hydroxide or magnesium hydroxide have a faster onset?

magnesium hydroxide

does aluminum hydroxide or magnesium hydroxide have a longer duration?

aluminum hydroxide

what side effect can happen with frequent use of aluminum hydroxide?

decreased phosphate (hypophosphatemia)

exclusion for magnesium hydroxide

creatinine clearance < 30 mL/min

exclusion for aluminum hydroxide

renal failure (can lead to aluminum toxicity)

what should you recommend for a pt with chest pain?

refer to dr

what HB med must be avoided in elderly pt w risk for delirium?

famotidine

when can famotidine be taken?

at symptom onset or before known trigger

what is the famotidine dose for mild HB?

10 mg

what is the famotidine dose for moderate HB?

20 mg

risks of long term omeprazole use (unlikelyl if taking correctly OTC)

• infection

• fracture

• vitamin B12 deficiency

• Mg deficiency

• iron deficiency

• chronic kidney disease

• dementia

counseling note for milk of magnesia

hydrate— can cause diarrhea

what is included in pepcid complete?

famotidine + ca carbonate + mg hydroxide