Lecture 6 OTC GERD/Heartburn Meghji GASTROESOPHAGEAL REFLUX DISEASE: • “A condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications” (Montreal Classification) • Most common symptoms for mild GERD: o Heartburn (burning sensation along esophagus) o Regurgitation (acid/bile that rises to the back of the throat) • Features: o May wax and wane o Worse when lying down, bending over, or after a meal CAUSE IS MULTIFACTORIAL: • Relaxation/decreased integrity of the lower esophageal sphincter • Increased lower abdominal pressure • Delayed gastric emptying • Impaired esophageal clearance/peristalsis • Excessive acid production • Hiatal hernia • Bile reflux GERD RISK FACTORS/TRIGGERS: • Being overweight/obese • Diet o Fatty foods/spicy foods o Chocolate* o Coffee * o Alcohol * o Carbonated drinks o Citrus fruits or juices o Garlic or onions o Mint (peppermint, spearmint) o Tomatoes • Pregnancy • Stress and anxiety • Age ( > 65) • Smoking * • Hiatus hernia * = weak associations MEDICATIONS THAT LOWER ESOPHAGEAL PRESSURE can induce or worsen GERD: • Alpha-adrenergic antagonists • Anticholinergics • Beta-agonists • Benzodiazepines (diazepam) • CCBs (nifedipine, felodipine, amlodipine) • Nicotine • Nitrates • Opioids • Progesterone • Theophylline DRUG INDUCED DYSPEPSIA/ESOPHAGITIS: • Acarbose • Amiodarone • Antibiotics o Erythromycin o Tetracyclines • Bisphosphonates • Potassium chloride • Clindamycin • Digitalis • Ethanol • Iron • NSAIDs • Quinidine ALARM SYMPTOMS & WHEN TO REFER: • Chest pain: radiating pain to shoulders, neck, arm, SOB, sweating • Vomiting: continuous/recurrent • GI blood loss: hematemesis, melena • Dysphagia (difficulty swallowing), especially solids • Odynophagia (severe pain on swallowing) • Unexplained weight loss > 5% • Unexplained cough, wheezing, choking, hoarseness • Age > 50 years old with new symptoms • Severe symptoms (frequency, rating) • Nocturnal symptoms • Failure of 2 week H2RA/PPI therapy WHY CHECK FOR ALARM SX? Symptoms could be due or lead to: • Cardiac disease • PUD • Malignancy • Functional dyspepsia • Biliary disease • Other GOALS OF THERAPY: • Treat symptoms (reduce/eliminate) • Reduce or prevent recurrence • Prevent structural damage and thus complications (e.g. ulcers) • Prevent ADRs of meds NON-PHARMACOLOGICAL TX: • Avoid foods/beverages that worsen or trigger symptoms • Eat small meals and chew food well • Avoid exercise after meals • Don’t lie down for 2-3 hours after eating • Avoid tight clothing • Encourage smoking cessation • Elevate head of bed frame (i.e. not extra pillows) about 10 cm • Achieve ideal body weight ► Individualize non-pharmacological therapy to triggers ► Evidence = inconclusive ANTACIDS: sodium bicarbonate and salts of aluminium, calcium and magnesium • MOA: neutralizes gastric acid • Potency: aluminum (least) < magnesium hydroxide < sodium bicarbonate < calcium carbonate (most potent) • Used in combination with each other (lots of products); dosing varies with products Advantages Disadvantages • Immediate relief of symptoms (faster than H2Ras/PPIs) o Liquids work faster than tablets • Cheap, unscheduled • Frequent dosing required o Short duration of action (0.5 – 1 hr, prolonged by food up to 3 hours) • Many drug interactions • Check sodium content INTERACTIONS: • May adsorb or chelate with other drugs ( tetracyclines, fluoroquinolones, iron) o Separate by at least 2 hours • Increases gastric pH changing absorption (ketoconazole, iron) • Premature breakdown of EC meds Ca carbonate Magnesium Aluminum Sodium bicarbonate Place in therapy • Most common agent used • Preferred in compromised renal function • Magnesium/aluminum combos used to offset constipation/diarrhea o Diarrhea dominates • Generally avoided • Not first line Caution/CIs • Hypercalcemia (total Ca intake) • Can lead to milk- alkali syndrome & hypophosphatemia (prolonged/use high doses) • Avoid in renal dysfunction and elderly (risk of hyperMg) • Avoid in renal dysfunction • Can lead to hypo-PO4 (prolonged use/high doses) • High Na content = avoid in high BP, HF, renal dysfunction, edema, cirrhosis, pregnancy, etc • Can cause metabolic alkalosis (prolonged use/high doses) Notable SEs • Belching • Flatulence • Constipating • Diarrhea • Constipating • Flatulence • Belching • Abdominal distension Examples • Tums • Maalox • Diovol • Milk of Magnesia • Gaviscon ES, max strength • Alugel, amphogel • Gaviscon RS • Alka-Seltzer (+ASA), ENO (sodium citrate) ALGINATE + ANTACID: alginic acid/sodium alginate • MOA: alginate forms a viscous layer on top of gastric contents = protective barrier • Advantages: immediate relief of symptoms o Formulated with antacids • Disadvantages: o Insufficient evidence as monotherapy o Unproven if combo with antacid is better o May contain high sodium content
4
Embed
Lecture 6 OTC GERD/Heartburn Meghji GASTROESOPHAGEAL ... · 2 Esomeprazole and its salts when sold for the 14-day treatment for frequent heartburn, at a daily dose of 20 mg and in
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
• Longer duration of action than antacids, quicker onset than a PPI
• Can be used with a prn antacid o Famotidine: available in combination with an antacid (Pepcid complete)
• Used for prevention (30 min-1 hr before aggravating food or trigger)
• Usually well tolerated (diarrhea, headache, dizziness, rash & tiredness)
• Not as rapid onset as an antacid
• Tachyphylaxis (use PRN?)
• Reduce dose in renal impairment
Schedule
1 Ranitidine and its salts (except when sold in concentrations of 150 mg or less per oral dosage unit and indicated for treatment of heartburn)
3 Ranitidine and its salts (when sold in concentrations of 150 mg or less per oral dosage unit and indicated for the treatment of heartburn, in package size containing more than 4500 mg of ranitidine)
1 Famotidine and its salts (except when sold in concentrations of 20 mg or less per oral dosage unit and indicated for the treatment of heartburn)
3 Famotidine and its salts (when sold in concentrations of 20 mg or less per oral dosage unit and indicated for the treatment of heartburn, in package size containing more than 600 mg of ranitidine)
1 Cimetidine and its salts (except when sold in concentrations of 100 mg or less per unit dose)
3 Cimetidine and its salts when sold in concentrations of 100 mg or less per unit dose (NO PRODUCTS CURRENTLY AVAILABLE)
1 Nizatidine (Rx only)
INTERACTIONS:
• Cimetidine inhibits 3A4, 2D6, 1A2, 2C9 and 2C19 = stay away as possible
• CYP450 interactions uncommon with non-prescription doses for ranitidine and famotidine
• MOA: decrease stomach acid production by blocking proton pump inhibitor (more potent)
• Similar effectiveness and safety profiles within class when given at eqipotent doses
• Dose: 20 mg once daily, best taken 30 minutes – 1 hour before meals
Advantages Disadvantages
• Prolonged duration of action and better symptomatic relief compared to H2Ras
• Once daily dosing
• Induces remission more frequently than H2Ras
• Usually mild SEs (constipation, diarrhea, headache)
• Onset: 3 hours (not for immediate relief)
• Increased infections (CAP, C. diff), fracture risk?, B12 deficiency, hypomagnesia, iron malabsorption (not an OTC use concern)
Schedule
1 Esomeprazole and its salts except when sold for the 14-day treatment for frequent heartburn, at a daily dose of 20 mg and in package sizes of no more than 280 mg of esomeprazole
2 Esomeprazole and its salts when sold for the 14-day treatment for frequent heartburn, at a daily dose of 20 mg and in package sizes of no more than 280 mg of esomeprazole
1 Omeprazole or its salts except when sold for the 14-day treatment for frequent heartburn at a daily dose of 20 mg in package sizes of no more than 280 mg of omeprazole
2 Omeprazole or its salts when sold for the 14-day treatment for frequent heartburn at a daily dose of 20 mg in package sizes of no more than 280 mg of omeprazole
• Indicated: when abdominal gas associated with high fibre foods
(contain high amounts of oligosacch), foods high in oligosaccharides o Vegetables: parsley, onions, lettuce, leeks, cucumbers, corn, cauliflower, cabbage,
brussel sprouts, broccoli, beets
o Beans: black-eyed, broad, chickpeas, bag beans, lima beans, mung beans, peanuts