GERD

• belching
• globulous sensation
• heartburn
• regurgitation
• sour stomach
• water brash

• chest pain (like angina)
• nonallergic asthma
• chronic cough
• hoarsness
• pharyngitis
• dental erosions

• dysphagia - difficulty swallowing
• odynophagia - pain on swallowing
• unexplained weight loss
• GI bleeding

• irritability
• fussiness
• hiccups
• in ability to sleep
• frequent vomiting
• refusal to eat
• frequent cough and coughing fits

• alarm symptoms
• atypical symptoms
• childrend <12 yo
• failure to respond to OTC therapy

trouble symptoms more than or equal to 2 times/week

give empiric treatment, it symptoms get better, then diagnosis is made

patient has alarm or atypical symptoms or they don't respond to therapy

• endoscopy (gold standard)
• PillCam Eso
• 24 hr Ambulatory pH monitoring

• pH probe
• radiotelemetry capsule

• increase LES pressure
• dec volume of gastric content available for reflux
• inc the pH of the refluxate
• enhance esophageal acid clearance
• improve gastric emptying
• protect esophageal mucosa

• lifestyle modification PLUS
• antacids AND/OR
• OTC doses of H2 blockers prn

• lifestyle modification AND
• antacids OR
• OTC H2RAs OR
• OTC PPIs for 2 weeks

• lifestyle modifications PLUS
• standard Rx H2RAs for 6-12 weeks OR
• PPIs for 4-8 weeks

• lifestyle modifications PLUS
• PPIs for 4-16 weeks

can use high dose H2RAs for 8-12 weeks (but NOT RECOMMENDED)

• chocolate
• peppermints
• alcohol
• fatty foods

• antichollinergics
• Beta blockers
• Ca channel blockers
• nitrates
• theophyline

• tetracyclines
• KCl
• Fe
• ASA
• NSAIDs
• qunidine
• bisphosphonates

• neutralize existing acid -->
• dec conversion of pepsinogen to pepsin
• inc LES pressure

• onset: 5-15 min
• DOA: 1-3 hrs (give after meals to inc DOA)

reacts with sodium bicarb and saliva to create a viscous solution that is refluxed before and in the place of gastric acid

less neutralizing capacity or inc in LES pressure, but more effective than antacids alone

dosed based on ANC (acid neutralizing capacity)

AlOH

• in upright position
• not before bedtime
• thoroughly chew tablets
• followed by full glass of water

• osmotic diarrhea
• accumulation/toxicity in renal disease

• depressed reflexes
• muscle paralysis
• hypotension
• bradicardia

• dose related constipation (can lead to obstruction)
• hypophosphatemia and bone demineralization (b/c binds to phosphate)
• accumulation/toxicity in renal disease

• dec bowel motility
• dehydration or fluid restriction

• diarrhea (but less than with Mg containing products)
• accumulation/toxicity in renal disease
• binding of phosphate - bone demineralization

• belching
• flatulence
• consitpation
• acid rebound (hypersecretion when the antacid leaves the stomach)
• hypercalcemia
• complications in renal disease

• confusion
• memory impairment
• kidney stones
• reduced renal function

• belching
• flatulence
• Na overload
• metabolic alkalosis (b/c of systemic absorption) in renal disease
• Milk-alkali syndrome

type of metabolic alkalosis caused by chronically ingesting Na bicarb with Ca

• vertigo
• irritability
• headache
• N/V
• weakness
• myalgias
• memory loss
• personality change
• coma
• renal failure

• onset: 1 hr
• DOA: 6-12 hrs

can prevent heartburn if given 30-60 min b4 eating problematic foods

• given BID for 6-12 weeks
• not effective in erosive GERD

competes with histamine for inhibition of the H2 receptors to decrease acid secretion from the parietal cells

• inc gastric pH
• dec activation of pepsinogen
• dec volume of gastric content available for reflux

• lower OTC doses not affected by renal function
• standard doses need to be adjusted

ranitidine 2 mg/kg BID

cimetidine

generally well tolerated

basically all drugs that need acidic medium for absorption

• heartburn that occurs more than 2 times/week
• take daily (not effective with prn use)

• irreversible binding of H-K ATPase pump on parietal cells
• irreversible inhibition of final step of gastric acid release

only the ones that are actively secreting

relief in 4 days

• usually QD
• can be BID if QD doesn't work (b4 considering treatment failure)

mild heartburn: for 14 days (don't take for longer unless under MD supervision; don't self treat more than every 4 mos unless otherwise told by MD)

symptomatic GERD: for 4-8 weeks

healing of erosive esophagitis: for 4-12 wks

4 weeks of BID initially

• 30 min before first morning meal
• second dose is 30 min before evening meal

can also do BID for first 2-3 days of therapy; can also do H2RA combo for first 2-3 days of QD therapy

omeprazole (Zegerid)

dual delayed release capsule with granules that can be sprinkled into things

• Vitamin B12 malabsorption
• hip fractures (b/c of malabsorption of Ca

• CYP 3A4 and CYP 2C19
• clopidogrel (pantoprazole has least interaction with this)
• monitor INR when taking with warfarin
• monitor phenytoin levels
• digoxin levels with rabeprazole

• bethanechol
• metoclopramide
• cisapride

• MOA: cholinergic stimulent, inc LES pressure and esophageal clearance
• AEs: ab cramps, diarrhea, blurred vision, inc urination
• DIs: other cholinergic and sympathomimetic agents

• MOA: dopamine antagonist, inc LES pressure, accel gastric emptying
• AEs: extrapyramidal effects, restlessnes, drowsiness, gynecomastia
• DIs: CNS depressants (additive), other dopamine antagonists or drugs that case extrapyramidal effects

• MOA: facilitates Ach release, inc LES pressure, accel gastric emptying
• AEs: cardiac arrhythmia, ab cramping, diarrhea
• DIs: life-threatening interaction with CYP 3A4 inhibitors, concurrent use with meds known to prolong QT interval

dose reduce in pts with renal or hepatic impairment

stomach fundus wrapped around distal esophagus

inc LES performance,