GI Exam 2 Part 3: Acid-Related Diseases

what does GERD stand for?

gastroesophageal reflux disease

what is gastroesophageal reflux?

passage of gastric contents into the esophagus

-normal physiologic process

-most episodes are asymptomatic

when does gastroesophageal reflux turn into GERD?

when this natural process ends up causing damage or symptoms

what is the most common disease encountered by gastroenterologists

GERD

what are the 2 classes of medications that can induce lower esophageal sphincter (LES) relaxation --> GERD

-anticholinergics

-TCAs

what are the 7 types of medications that can irritate the esophagus and cause GERD

-tetracycline

-biphosphonates

-iron supplements

-NSAIDs, aspirin

-Dabigatran

-steroids

-potassium supplements

what are the 4 non-medication causes of GERD

-pregnancy

-obesity

-fatty meals, chocolate, carbonated beverages

-disorders of the esophagus

what are the 2 typical symptoms of GERD

heartburn and regurgitation

what are 3 atypical symptoms of GERD

-gas, bloating, burping (indigestion)

-epigastric pain

-nausea

what are the 5 extra-esophageal symptoms of GERD that should make a patient see a GI doctor

-chronic cough

-asthma-like symptoms

-recurrent sore throat

-laryngitis

-dental enamel loss

what are the 3 symptoms of GERD that are an alarm (should send the patient to the ED)

-dysphagia

-choking

-chest pain

how is GERD diagnosed?

typical symptoms of heartburn/digestion and regurgitation and response to anti-secretory therapy

pts with extra-esophageal/alarm symptoms will need more invasive testing

what are the 3 presentations of acid-related diseases?

1. NERD (non-erosive reflux disease)

2. GERD with complications

a. erosive esophagitis

b. Barrett's esophagitis

non-erosive reflux disease (NERD) characteristics

o   Typical reflux symptoms

o   No visible mucosal damage of esophagus

o   Treatment rarely life-long

what is erosive esophagitis

visible mucosal damage of the esophagus

what is Barrett's esophagitis

tissue changes resembling the lining of the intestine

complications of GERD

dysplasia followed by adenocarcinoma

what are the 4 GERD treatment goals

· Reduce the frequency and duration of reflux

· Symptom reduction or elimination

· Promote healing of injured mucosa

· Prevent disease progression and complication

what are teh 7 exclusions for self-treatment of GERD?

· Symptoms > 3 months

· Heartburn despite 2 weeks of OTC therapy

· Nocturnal heartburn

· Alarm symptoms

· Vomiting

· Unexplained weight loss

· Chronic cough

what are the 3 overall GERD treatment options

· Lifestyle modifications

· Medications

· Surgery

what are 5 lifestyle modifications that can help treat GERD?

· Weight loss for patients that are overweight

· Head of bed elevation

· Smoking cessation

· Avoidance of meals 2-3 hours before bedtime

· Selective elimination of foods that can trigger reflux

which foods can be eliminated in GERD patients that trigger reflux?

o Caffeine, alcohol, chocolate

o Acidic or spicy foods

o Reduce fat or portion size

when should step-up treatment of GERD be used?

fewer than 2 episodes/week (mild/intermittent)

what is step-up treatment of GERD

start with lower-dose OTC products (antacids, H2RAs)

what are 3 advantages of step-up treatment for GERD

§ Avoid overtreatment

§ Lower initial medication cost

§ Potentially lower risk of ADEs

what are 2 disadvantages of step-up treatment for GERD

§ Risk of undertreatment

§ May take longer for symptom control

when should step-down treatment of GERD be used?

more than 2 episodes/week

what is step-down treatment of GERD

Start with maximum therapy (PPI)

2 advantages of step-down treatment of GERD

-rapid symptom relief

-patient satisfaction

3 disadvantages of step-down treatment of GERD

-potential overtreatment

-higher medication costs

-increased risk of ADEs

step-down treatment of patients with classic GERD symptoms

once daily PPI x 8 weeks

once managed, taper off with antacid/H2RA

step-down treatment of patiets with combined extraesophageal and typical GERD symptoms

BID PPI x 8-12 weeks

once managed, taper off with antacid/H2RA

5 advantages of using antacids

o OTC

o Inexpensive

o Relatively safe

o Rapid relief

o Take PRN

4 disadvanatges of antacids

o Short duration of action

o Drug interactions

o Chelation of other medications (doxycycline, ciprofloxacin)

o Risk of electrolyte imbalances with renal insufficiency

what is the most common calcium salt antacid

Tums

what is the antacid preferred in pregnancy

calcium salts (Tums)

what are 2 ADEs of calcium salt antacids/ Tums

hypercalcemia and constipation

Magnesium hydroxide (milk of magnesia) ADEs

Risk of Mg toxicity (muscle weakness) and diarrhea

brand name of Mg hydroxide

mylanta classic

aluminum hydroxide vs magnesium hydroxide

Mg is more effective than Al

ADEs of aluminum hydroxide

constipation (Mg added helps)

risk of accumulation (neurotoxicity) with renal dysfunction

Alka seltzer ingredients

aspirin/citric acid/sodium bicarbonate

why can alka-seltzer cause belching

reacts with stomach HCL to release CO2

max TDD of alka-seltzer

9.6mg/day due to high sodium content

ADEs of alka-seltzer

has a high sodium content...

-HF, HTN

-cirrhosis

-CKD

what 3 types of patient should aka-seltzer be avoided in and why?

Contains aspirin for pain relief

§  Avoid in aspirin-allergic patients

§  Reye’s disease

§  Avoid in patients with high risk for GI bleeding

gaviscon ingredients

Aluminum hydroxide, Mg carbonate and alginate

MOA of gaviscon

Alginic acid is a polymer that precipitates into a viscous gel within minutes of contacting gastric acid and floats atop gastric contents

DDI of gaviscon

can impact absorption of other meds, separate by 2 hours

dosage forms and dosing of gaviscon

chewable tablet or liquid

PRN dosing, check label

bismuth subsalicylate brand name

pepto bismol

bismuth subsalicylate MOA

bismuth has antimicrobial effects on bacterial pathogens, while salicylic acid moiety exerts anti-secretory effects

what 3 populations should bismuth subsalicylate be avoided in?

high salicylate content

o   Avoid if allergic to aspirin

o   Avoid in ulcer/bleeding disorders

o   Avoid in children/teens with viral symptoms

2 counseling points of bismuth subsalicylate

can cause black stool and black tongue

3 advantages of H2RAs

o Duration of action 4-10 hours

o Prophylactic efficacy

o Well tolerated

2 disadvantages of H2RAs

o More expensive than antacids

o Dose as needed

is there a difference between each H2RA drug?

no! they're all equally efficacious and considered interchangeable

OTC vs RX H2RAs

all available as both OTC ad Rx

Rx is usually 2x the dose of the OTC medication

meals and H2RAs

don't have to time them a specific way with eating

most common ADEs of H2RAs

mainly CNS effects

o HA, dizziness, fatigue, sleepiness

o Confusion (elderly, renal impairment)

what is the less common ADE of H2RAs

thrombocytopenia

what can occur with proloned daily use of H2RAs

tolerance can occur

how long should self-treatment with H2RAs be limited to?

maximum of 2 weeks BID

DDIs of H2RAs

can interact with drugs that depend on acid for absorption

-protase inhibitors

-calcium carbonate

-iron

famotidine dosing

once-twice a day

Ranitidine brand name

Zantac

which H2RA used to be available but was recalled

Ranitidine (Zantac)

cimetidine brand name

tagamet

which H2RA should be never recommended and 4 reasons why

cimetidine (Tagamet)

has LOTs of sodium

decreases testosterone binding to androgen receptor

inhibits renal cation transport system

inhibits many CYP enzymes

contraindications of cimetidine

CVD, CKD, or cirrhosis

androgenic ADEs of cimetidine

· Decreases testosterone binding to androgen receptor

o Inhibits CYP enzyme that hydroxylates estradiol

o Gynecomastia, reduced sperm count, and impotence in men

which 2 medications may be elevated with use of cimetidine

due to inhibition of renal cation transport system

-dofetilide

-metformin

sulcralfate brand name

carafate

MOA of sucralfate

· in pH ,4, cross links to produce viscous, sticky polymer that adheres to epithelial cells and ulcers for up to 6 hours

o Not systemically absorbed

is sucralfate Rx or OTC?

Rx only

renal dysfunction and sucralfate

aluminum complex may accumulate in renal dysfunction

counseling points of sucralfate

o   Take on an empty stomach one hour before meals

o   2-4 times a day

o   Constipation

o   Viscous layer may inhibit absorption of other medications

Separateby at least 2 hours

MOA of PPIs

·      block gastric acid secretion by irreversibly binding to and inhibiting the hydrogen-potassium ATPase pump that resides on the parietal cell membrane

·      Prodrugs that require acidic pH for activation

when should PPIs generally be administered?

give 30-60 mins before meals

duration of action of PPIs

o Acid secretion resumes only after new pump is synthesized

o Provides acid suppression up to 48 hours

are all pumps of parietal cells activated simultaneously?

no! multiple doses of PPIs may be required (2-5 days)

what is the benefit of delayed-release PPIs

allow tablets to reach alkaline pH in small intestine to avoid acid degradation in gastric lumen

counseling point of PPIs

Do not crush or chew

which PPI capsules can be opened and sprinkled into food

"OLDER"

o   Omeprazole (Prilosec)

o   Lansoprazole (prevacid)

o   Dexlansoprazole (delixant)

o   Esomeprazole (Nexium)

o   Rabeprazole (Aciphex)

omeprazole brand name

prilosec

lansoprazole brand name

prevacid

dexlansoprazole brand name

delixant

esomeprazole brand name

nexium

rabeprazole brand name

aciphex

which 3 PPIs are OTC

esomeprazole, lansoprazole, and omeprazole

how many times should PPIs be given per day

1-2 times a day

what are the 2 exceptions for PPIs being administered 30-60 mins before 1st meal

§  Omeprazole-sodium bicarbonate is an IR formulation and can be used for nocturnal symptoms before bed

§  Dexlansoprazole has dual delayed release mechanism and can be given without regards to meals

omeprazole-sodium bicarbonate brand name

Zegerid

pantoprazole brand name

protonix

PPIs vs H2RAs

PPIs have faster healing and more complete heartburn relief vs H2RAs

how long should PPIs be used

8-12 weeks, try to taper after

some patients (Barrett's esophagus) may be on life-long therapy

what are different ways patients can be tapered off of PPIs

o Some patients may need to reduce the dose by 50% every 2-4 weeks

o Can recommend H2RA or antacid available PRN with taper

o Some patients just stop abruptly without rebound GERD

warnings with long-term use of PPIs

can decrease Mg levels

osteoporosis (mixed data)

why is osteoporosis a concern with long-term use of PPIs

o   Certain types of Ca require acidic environments to be absorbed

o   Guidelines say osteoporosis should not affect the decision to use PPI long-term except in patients with other risk factors for hip fracture

chronic PPI ADEs

· Decreased B12 levels due to impaired absorption

· Potentially related to dementia ?? (need more data)

· Increased risk of pneumonia in the hospital

· Increased risk of enteric (stomach) infections in the hospital