self-care heartburn, constipation, diarrhea - exam 3

what is the SCHOLAR-CAMP for heartburn?

-burning sensation that usually arises from the substernal area and moves up toward the neck or throat

-listen for risk factors

-30-80% of pregnant women complain of heartburn, mostly in the 1st and 3rd trimesters

-how often are symptoms occurring?

what are some diseases that may contribute to heartburn?

-motility disorders (increase volume in stomach and intra-abdominal pressure)

-peptic ulcer disease

-scleroderma

-Zollinger-Ellison Syndrome (excrete excess acid)

-obesity

what are some lifestyle factors that may contribute to heartburn?

-exercise

-smoking (tobacco)

-stress

-supine body position

-tight fitting clothing

what are some dietary factors that may contribute to heartburn: decrease LES pressure?

-alcohol

-caffeinated beverages

-chocolate*

-mint

-fatty foods

-garlic and onions

what are some dietary factors that may contribute to heartburn: direct irritants?

-citrus fruit or juices

-coffee

-salt and salt substitutes

-spicy foods

-tomatoes/tomato juice

what are some other risk factors that may contribute to heartburn?

-pregnancy

-geriatrics

what are some medications that may contribute to heartburn: decrease LES pressure?

-anti-cholinergic*

-barbiturates

-CCB*

-estrogen

-tetra/doxycycline

-theophylline

-dopamine

-nitrates

-progesterone

what are some medications that may contribute to heartburn: direct irritants?

-bisphosphonates*

-ASA/NSAIDs*

-chemotherapy

-clindamycin

-iron*

-potassium*

-quinidine

what are some other medications that may contribute to heartburn?

-benzodiazepines

-beta2 agonist

-PGs

-TCAs

-zidovudine

-alpha antagonist

-narcotic analgesics

treat or refer: frequent heartburn for more than 3 months

refer

treat or refer: heartburn continues or worsens while taking recommended dosages of OTC H2RA or PPI

refer

treat or refer: heartburn that continues after 2 weeks of continuous treatment with OTC H2RA, PPI, or with max dosage of antacid

refer

treat or refer: sever heartburn and dyspepsia (affecting daily life)

refer

treat or refer: difficulty or pain on swallowing solid foods

refer

treat or refer: chronic hoarseness, wheezing, coughing

refer

treat or refer: continuous nausea, vomiting, or diarrhea

refer

treat or refer: children younger than 2 years (for antacids), 12 years (for H2RA) or 18 years (for PPI)

refer

what are the exclusions for self-treatment of heartburn?

-frequent heartburn for more than 3 months

-heartburn continues or worsens while taking recommended dosages of OTC H 2RA or PPI

-heartburn that continues after 2 weeks of continuous treatment with OTC H 2RA or PPI or with maximum dosage of antacid

-severe heartburn and dyspepsia

-difficulty or pain on swallowing solid foods

-chronic hoarseness, wheezing, coughing

-continuous nausea, vomiting, or diarrhea

-children younger than 2 year (for antacids), 12 years (for H 2RA) or 18 years (for PPI)

what are some alarm symptoms that warrant an immediate referral to a gastroenterologist or PCP?

-anemia

-epigastric mass

-dysphagia

-vomiting up blood or black material or passing black tarry stools

-choking

-unexplained weight loss

-chest pain accompanied by sweating, pain radiating to shoulder, arm, neck or jaw and

shortness of breath

what is the diagnostic criteria for heartburn?

-pt reported symptoms

-severe or refractory cases may be further examined via esophagealgastroduodenoscopy (EGD), esophageal biopsy, or barium swallow

-simple/episodic heartburn

-frequent heartburn

what is simple/episodic heartburn?

typically mild, infrequent and associated with lifestyle

what is frequent heartburn?

2 or more days per week or if no response to H2RA

what are some other GI disorders that need to be ruled out that require different diagnostic criteria and treatment stategies?

-dyspepsia

-GERD

-PUD

what is dyspepsia?

postprandial fullness, early satiety, belching, mild pain/burning, bloating, N/V

what is GERD?

heartburn symptoms and acid regurgitation

what is PUD?

gnawing or burning pain occurring during the day and frequently at night

what are the goals of treatment for heartburn?

-reduce frequency and duration of reflux

-reduce and eliminate symptoms

-prevent disease progression and development of complications

-promote healing of injured GI mucosa

when are lifestyle modifications recommended for heartburn?

recommended for everyone with symptoms and needs to be individualized for each patient

what are the lifestyle recommendations for heartburn treatment?

-vvoid foods and beverages that precipitates heartburn

-weight loss for obese patients

-elevate head of bed with 6 in blocks underneath legs of bed or a foam wedge

-eat smaller meals and reduce intake of dietary fat

-refrain from eating 3 hours before lying down/going to bed

-evaluate medications for potential problems

-discourage tobacco use

-limit alcohol and caffeine intake if those contribute to heartburn

how is therapy chosen for heartburn treatment?

based on frequency of symptoms

-simple/episodic heartburn

-frequent heartburn

what is the treatment for frequent heartburn (≥ 2 days per week)?

lifestyle modifications AND OTC PPI once daily for 14 days

what is the follow-up to assess response for frequent heartburn?

-if not resolved refer to physician

-if resolved: stop PPI (may repeat every 4 months if needed)

what is the treatment for episodic heartburn (< 2 days per week; usually associated with lifestyle/dietary risk factors)?

lifestyle modifications

AND antacid OR OTC H2RA

OR bismuth subsalicylate

what is the follow up to assess response to episodic heartburn?

-ff not resolved, consider different OTC antacid or H2RA, or treat with OTC PPI or medical referral

-if resolved: Continue lifestyle

modifications; may repeat treatment for up to 2 weeks if symptoms recur

what are the 4 different types of antacids?

1. magnesium

2. aluminum

3. calcium

4. sodium bicarbonate

what is the onset of action for magnesium antacids?

<5 minutes

what is the duration of action for magnesium antacids?

20-30 minutes (up to 3hr with food)

what is the MOA for magnesium antacids?

-neutralize gastric acidity

-increase pressure of lower esophageal sphincter

-blocks conversion of pepsinogen to pepsin

what are the adverse effects of magnesium antacids?

diarrhea

what are the drug/drug interactions with magnesium antacids?

-tetracyclines

-azithromycin

-fluoroquinolones

what are the precautions/contraindications with magnesium antacids?

renal insufficiency

what is the onset of action for aluminum antacids?

<5 minutes quicker than sodium/magnesium

what is the duration of action for aluminum antacids?

20-30 minutes (up to 3hr with food) (longer than sodium/magnesium)

what is the MOA of aluminum antacids?

-neutralize gastric acidity

-increase pressure of lower esophageal sphincter

-blocks conversion of pepsinogen to pepsin

what are the adverse effects of aluminum antacids?

-constipation

-hypophosphatemia

what are the precautions/contraindications for aluminum antacids?

renal insufficiency

what is the onset of action for calcium antacids?

<5 minutes quicker than sodium/magnesium

what is the duration of action for calcium antacids?

20-30 minutes (up to 3hr with food) (longer than sodium/magnesium)

what is the MOA of calcium antacids?

-neutralize gastric acidity

-increase pressure of lower esophageal sphincter

-blocks conversion of pepsinogen to pepsin

what are the adverse effects of calcium antacids?

-constipation

-belching

-flatulence

-acid rebound

-hypercalcemia

what are the drug/drug interactions with calcium antacids?

-itraconazole

-ketoconazole

-iron

what are the precautions/contraindications for calcium antacids?

renal insufficiency

what is the onset of action for sodium bicarbonate antacids?

<5 minutes

what is the duration of action for sodium bicarbonate antacids?

20-30 minutes (up to 3hr with food)

what is the MOA of sodium bicarbonate antacids?

-neutralize gastric acidity

-increase pressure of lower esophageal sphincter

-blocks conversion of pepsinogen to pepsin

what are the adverse effects of sodium bicarbonate antacids?

-belching

-flatulence

-fluid overload

what are the precautions/contraindications for sodium bicarbonate antacids?

-renal insufficiency

-CHF

-cirrhosis

what are the 3 histamine-2 receptor antagonists?

-cimetidine 200mg (Tagamet)

-famotidine 10mg (Pepcid)

-nizatidine 75mg (Axid XR)

what is the onset of action for cimetidine?

within 1 hr

what is the duration of action of cimetidine?

10-12 hrs

what is the dosing for cimetidine?

1 tablet daily (max 1 tab twice daily)

what is the MOA of cimetidine?

decreases gastric acid secretion by inhibiting H2 receptors on parietal cells

what are the adverse effects of cimetidine?

headache, diarrhea, constipation, dizziness, drowsiness

what is the counseling for cimetidine?

-take with a full glass of water

-take at onset of symptoms or 30-60 min before an event where symptoms are expected

what are the drug/drug interactions with cimetidine?

-inhibit several CYP enzymes resulting in numerous drug interactions (phenytoin, warfarin, theophylline, TCAs, amiodarone)

-inhibits CYP2C19 (clopidogrel)

what are the precautions/contraindications with cimetidine?

-reduced dose in renal impairment (CrCl <50 mL/min)

-reduced dose in pts of advanced age

what is the onset of action of famotidine?

within 1 hr

what is the duration of action of famotidine?

10-12 hrs

what is the dosing for famotidine?

1 tablet daily (max 1 tab twice daily)

what is the MOA of famotidine?

decreases gastric acid secretion by inhibiting H2 receptors on parietal cells

what are the adverse effects of famotidine?

headache, diarrhea, constipation, dizziness, drowsiness

what is the counseling for famotidine?

-take with a full glass of water

-take at onset of symptoms or 30-60 min before an event where symptoms are expected

what are the drug/drug interactions with famotidine?

-inhibit several CYP enzymes resulting in numerous drug interactions (phenytoin, warfarin, theophylline, TCAs, amiodarone)

-inhibits CYP2C19 (clopidogrel)

what are the precautions/contraindications with famotidine?

-reduced dose in renal impairment (CrCl <50 mL/min)

-reduced dose in pts of advanced age

what is the onset of action of nizatidine?

within 1 hr

what is the duration of action of nizatidine?

10-12 hrs

what is the dosing for nizatidine?

1 tablet daily (max 1 tab twice daily)

what is the MOA of nizatidine?

decreases gastric acid secretion by inhibiting H2 receptors on parietal cells

what are the adverse effects of nizatidine?

headache, diarrhea, constipation, dizziness, drowsiness

what is the counseling for nizatidine?

-take with a full glass of water

-take at onset of symptoms or 30-60 min before an event where symptoms are expected

what are the drug/drug interactions with nizatidine?

-inhibit several CYP enzymes resulting in numerous drug interactions (phenytoin, warfarin, theophylline, TCAs, amiodarone)

-inhibits CYP2C19 (clopidogrel)

what are the precautions/contraindications with nizatidine?

-reduced dose in renal impairment (CrCl <50 mL/min)

-reduced dose in pts of advanced age

what are the 3 proton pump inhibitors?

1. omeprazole 20.6mg (Prilosec)

2. esomeprazole 20mg (Nexium)

3. lansoprazole 15mg (Prevacid)

what is the onset of action of omeprazole?

30 min to 1 hr

-might take pt ~2 hrs to actually start feeling relief

what is the duration of action of omeprazole?

~24 hrs

what is the dosing for omeprazole?

1 tablet/capsule daily

what is the MOA of omeprazole?

decrease gastric acid secretion by inhibiting H+/K+ ATPase pumps

what are the adverse effects of omeprazole?

diarrhea, constipation, headache

what is the counseling for omeprazole?

-do not crush or chew

-take with a full glass of water

-take 30-60 min before the morning meal

what are the drug/drug interactions with omeprazole?

-may inhibit CYP2C19 (clopidogrel, diazepam, phenytoin, warfarin, theophylline, tacrolimus, cilostazol)

-interferes with elimination of methotrexate

what are the precautions/contraindications for omeprazole?

chronic acid suppression can lead to increased risk of infection, fractures in the elderly, and rebound acid hypersecretion

what is the onset of action of esomeprazole?

30 min to 1 hr

-might take pt ~2 hrs to actually start feeling relief

what is the duration of action of esomeprazole?

~24 hrs

what is the onset of action of lansoprazole?

30 min to 1 hr

-might take pt ~2 hrs to actually start feeling relief

what is the duration of action of lansoprazole?

~24 hrs

what is the MOA of esomeprazole?

decrease gastric acid secretion by inhibiting H+/K+ ATPase pumps

what is the dosing for esomeprazole?

1 tablet/capsule daily

what are the drug/drug interactions with esomeprazole?

-may inhibit CYP2C19 (clopidogrel, diazepam, phenytoin, warfarin, theophylline, tacrolimus, cilostazol)

-interferes with elimination of methotrexate

what are the precautions/contraindications for esomeprazole?

chronic acid suppression can lead to increased risk of infection, fractures in the elderly, and rebound acid hypersecretion

what is the counseling for esomeprazole?

-do not crush or chew

-take with a full glass of water

-take 30-60 min before the morning meal