1. Typical symtpoms of GERD
    • belching
    • globulous sensation
    • heartburn
    • regurgitation
    • sour stomach
    • water brash
  2. Atypical symptoms of GERD
    • chest pain (like angina)
    • nonallergic asthma
    • chronic cough
    • hoarsness
    • pharyngitis
    • dental erosions
  3. alarm symptoms
    • dysphagia - difficulty swallowing
    • odynophagia - pain on swallowing
    • unexplained weight loss
    • GI bleeding
  4. symptoms of GERD in infants
    • irritability
    • fussiness
    • hiccups
    • in ability to sleep
    • frequent vomiting
    • refusal to eat
    • frequent cough and coughing fits
  5. Which GERD symptoms require MD referral
    • alarm symptoms
    • atypical symptoms
    • childrend <12 yo
    • failure to respond to OTC therapy
  6. clinical diagnosis of GERD
    trouble symptoms more than or equal to 2 times/week

    give empiric treatment, it symptoms get better, then diagnosis is made
  7. further diagnostic evaluation of GERD symptoms is needed to make diagnosis if:
    patient has alarm or atypical symptoms or they don't respond to therapy

    • endoscopy (gold standard)
    • PillCam Eso
    • 24 hr Ambulatory pH monitoring
  8. types of ambulatory pH monitoring
    • pH probe
    • radiotelemetry capsule
  9. 6 mechanism of therapeutic intervention
    • 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
  10. treatment for symptomatic relief of intermittent, mild heartburn
    • lifestyle modification PLUS
    • antacids AND/OR
    • OTC doses of H2 blockers prn
  11. treatment for symptomatic of relief of mild heartburn occurring more than 2 times/week
    • lifestyle modification AND
    • antacids OR
    • OTC H2RAs OR
    • OTC PPIs for 2 weeks
  12. treatment for typical GERD symptoms
    • lifestyle modifications PLUS
    • standard Rx H2RAs for 6-12 weeks OR
    • PPIs for 4-8 weeks
  13. treatment for healing of erosive esophagitis or patients with complication or atypical symptoms
    • lifestyle modifications PLUS
    • PPIs for 4-16 weeks

    can use high dose H2RAs for 8-12 weeks (but NOT RECOMMENDED)
  14. Foods that dec LES tone
    • chocolate
    • peppermints
    • alcohol
    • fatty foods
  15. drugs that promote reflux
    • antichollinergics
    • Beta blockers
    • Ca channel blockers
    • nitrates
    • theophyline
  16. direct irritant drugs
    • tetracyclines
    • KCl
    • Fe
    • ASA
    • NSAIDs
    • qunidine
    • bisphosphonates
  17. Antacid MOA
    • neutralize existing acid -->
    • dec conversion of pepsinogen to pepsin
    • inc LES pressure
  18. onset and duration of antacids
    • onset: 5-15 min
    • DOA: 1-3 hrs (give after meals to inc DOA)
  19. Alginic Acid MOA
    reacts with sodium bicarb and saliva to create a viscous solution that is refluxed before and in the place of gastric acid
  20. Alginic acid compared to antacids
    less neutralizing capacity or inc in LES pressure, but more effective than antacids alone
  21. antacid dosing
    dosed based on ANC (acid neutralizing capacity)
  22. which antacid offers an adequate ANC w/ least potential for side effects?
  23. how should Gaviscon be given?
    • in upright position
    • not before bedtime
    • thoroughly chew tablets
    • followed by full glass of water
  24. AEs of Mg products
    • osmotic diarrhea
    • accumulation/toxicity in renal disease
  25. Mg toxicity
    • depressed reflexes
    • muscle paralysis
    • hypotension
    • bradicardia
  26. AEs of Al products
    • dose related constipation (can lead to obstruction)
    • hypophosphatemia and bone demineralization (b/c binds to phosphate)
    • accumulation/toxicity in renal disease
  27. patients to avoid use of Al products in:
    • dec bowel motility
    • dehydration or fluid restriction
  28. AEs of Mg-Al product combos
    • diarrhea (but less than with Mg containing products)
    • accumulation/toxicity in renal disease
    • binding of phosphate - bone demineralization
  29. AEs of CaCO3 containing products
    • belching
    • flatulence
    • consitpation
    • acid rebound (hypersecretion when the antacid leaves the stomach)
    • hypercalcemia
    • complications in renal disease
  30. complication of CaCO3 in renal dieases
    • confusion
    • memory impairment
    • kidney stones
    • reduced renal function
  31. AEs of Na bicarb products
    • belching
    • flatulence
    • Na overload
    • metabolic alkalosis (b/c of systemic absorption) in renal disease
    • Milk-alkali syndrome
  32. 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
  33. onset and DOA of H2RAs
    • onset: 1 hr
    • DOA: 6-12 hrs

    can prevent heartburn if given 30-60 min b4 eating problematic foods
  34. Standard doses of H2RAs
    • given BID for 6-12 weeks
    • not effective in erosive GERD
  35. H2RAs MOA
    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
  36. H2RAs and renal functions
    • lower OTC doses not affected by renal function
    • standard doses need to be adjusted
  37. pediatric H2RA dose
    ranitidine 2 mg/kg BID
  38. H2RA assoicated with the most AEs
  39. AEs of H2RAs
    generally well tolerated
  40. H2RA drug interactions
    basically all drugs that need acidic medium for absorption
  41. OTC PPI indication
    • heartburn that occurs more than 2 times/week
    • take daily (not effective with prn use)
  42. PPI MOA
    • irreversible binding of H-K ATPase pump on parietal cells
    • irreversible inhibition of final step of gastric acid release
  43. what pumps do the PPIs inhibit? and when can complete relief be felt?
    only the ones that are actively secreting

    relief in 4 days
  44. PPI dosing
    • 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
  45. PPI dosing for pts with atypical symptoms
    4 weeks of BID initially
  46. Administration of PPI
    • 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
  47. immediate release PPI
    omeprazole (Zegerid)
  48. dexlansoprazole
    dual delayed release capsule with granules that can be sprinkled into things
  49. PPI AEs
    • Vitamin B12 malabsorption
    • hip fractures (b/c of malabsorption of Ca
  50. PPI drug interactions
    • 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
  51. promotility agents in GERD
    • bethanechol
    • metoclopramide
    • cisapride
  52. Bethanechol MOA, AEs, DIs
    • MOA: cholinergic stimulent, inc LES pressure and esophageal clearance
    • AEs: ab cramps, diarrhea, blurred vision, inc urination
    • DIs: other cholinergic and sympathomimetic agents
  53. Metoclopramide MOA, AEs, DIs
    • 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
  54. Cisapride MOA, AEs, DIs
    • 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
  55. Nissen fundoplication
    stomach fundus wrapped around distal esophagus

    inc LES performance,
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Exam 1