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51 Cards in this Set
- Front
- Back
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What is the Montreal definition of Gastroesophageal Reflux Disease?
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A condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications.
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In what age group is GERD most common?
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Patients > 40 years of age.
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Is GERD more common in men or in women?
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GERD occurs equally among men and women.
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List four causative factors associated with GERD.
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1) Decreased esophageal clearance and mucosal resistance, 2) Decreased pressure of the LES (lower esophageal sphincter), 3) Caustic Agents (HCl, Pepsin, etc.), & 4) Increased intraabdominal pressure.
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List some foods said to decrease pressure of the lower esophageal sphincter.
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Peppermint/spearmint, chocolate, coffee, cola, tea, garlic, onions, chilli peppers, and fatty meals.
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Aside from certain foods and drugs, what else might decrease pressure of the lower esophageal sphincter.
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Smoking (nicotine) and alcohol.
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List four non-drug entities said to be direct irritants to the esophageal mucosa.
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Spicy foods, orange juice, tomato juice, and coffee.
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List four comorbidities/other factors associated with GERD.
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1) Family Hx, 2) Obesity, 3) Respiratory Disease, & 4) Chest Pain
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List 10 drugs or classes of drugs said to decrease pressure of the lower esophageal sphincter.
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Anticholinergics, Barbiturates, Caffeine, Dihydropyridine Calcium Channel Blockers, Dopamine, Estrogen, Nitrates, Progesterone, Tetracycline, & Theophylline.
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List 6 drugs said to be direct irritants to the esophageal mucosa.
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Bisphosphonates (alendronate), Aspirin, Iron, NSAIDs, Quinidine, & KCl.
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What is heartburn?
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Heartburn is "a burning sensation in the retrosternal area and moves up toward the neck or throat."
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What is the most common cause of gastroesophageal reflux?
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Heartburn
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What are four atypical, extra-esophageal syndromes having an established association with GERD?
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Dental Erosions, Chronic Laryngitis, Cough, & Asthma.
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What are four atypical, extra-esophageal syndromes "proposed" to have an association with GERD?
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Sinusitis, Pulmonary Fibrosis, Pharyngitis, & Recurrent Otitis Media
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What are the six "alarm symptoms" indicating potential complications of GERD?
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1) Unexpected weight loss, 2) Bleeding, 3) Choking, 4) Dysphagia (difficulty swallowing), 5) Odynophagia (pain w/ swallowing), & 6) Continual Pain.
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What are the Goals of Therapy with GERD?
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1) Alleviate or eliminate symptoms, 2) Promote healing of esophageal mucosal damage, 3) Prevent or decrease the frequency of recurrent GERD, & 4) Prevent complications.
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What are the 7 symptoms listed for the exclusion of GERD self-treatment?
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1) Frequent heartburn for more than 3 months; 2) Severe heartburn or dyspepsia; 3) Nocturnal heartburn; 4) Chronic hoarseness, wheezing, coughing; 5) Continuous nausea, vomiting, or diarrhea; 6) Chest pain accompanied by sweating, radiating pain, and SOB; & 7) Alarm symptoms present (i.e. weight loss, bleeding, choking, dysphagia, odynophagia, continual pain).
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List three exclusions for the self-treatment of GERD that are associated with medication use.
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1) Heartburn while taking recommended dosages of an OTC H2RA or PPI, 2) Heartburn that continues after 2 weeks of treatment with an OTC H2RA or PPI, & 3) Heartburn that occurs when taking a Rx H2RA or PPI.
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What age groups are exclusions for self-treatment of GERD?
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1) Pregnant and nursing mothers & 2) Children younger than 2 years (for antacids), 12 years (for H2RA), and 18 years (for PPIs).
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What is the recommendation from the self-care algorithm for the treatment of frequent heartburn, i.e. 2 or more day/wk?
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Lifestyle/dietary modifications and OTC PPI once daily for 14 days. If the symptoms resolve, stop the PPI (may repeat every 4 months if needed). If they don't resolve, give the patient a medical referral.
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What is the self-care algorithm recommendation for episodic heartburn, i.e. heartburn that occurs one day a week or less?
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Lifestyle/dietary modifications and antacid or alginic acid/antacid or either a OTC low-dose H2RA for mild, infrequent, episodic heartburn or a OTC higher-dose H2RA for moderate, infrequent, episodic heartburn. If symptoms resolve, continue lifestyle modifications (may repeat for up to 2 wks if symptoms recur). If symptoms don't resolve, try a different treatment, an OTC PPI, or provide a medical referral.
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List five general lifestyle modifications for GERD.
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1) Weight Loss, 2) Elevate the head of the bed, 3) Smoking cessation, 4) Avoid tight-fitting clothes, & 5) Identify medications that exacerbate symptoms and educate the patient about them.
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List six lifestyle modifications related to food that may alleviate GERD.
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1) Decrease fat intake, 2) Smaller meals, 3) More frequent meals, 4) Avoid laying down for 3 hrs postprandially, 5) Avoid alcohol, & 6) Avoidance of certain foods (chocolate, peppermint, coffee, onion, and garlic).
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What are the only two lifestyle modifications that evidence has shown are effective in helping to alleviate GERD?
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1) Weight loss & 2) Head of bed elevation. Both improve gastric pH profiles. Weight loss improved GERD symptoms.
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What is the mechanism of action for the treatment of GERD with antacids?
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Antacids increase intragastric pH.
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What is the onset of action and the duration of action of antacids used for relief of GERD?
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Onset of action: immediate ( < 5 min); Duration: 20 to 30 min (longer when taken w/ food).
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What is the main ADR with antacids? How does it differ when the antacid contains magnesium versus aluminum?
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Either diarrhea or constipation. Diarrhea is more frequent with Magnesium (think of the M standing for "move"), while constipation is more frequent with Aluminum.
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What ingredient, added to some antacid formulations, helps form a highly viscous solution that floats on the surface of the gastric contents to provide a protective barrier?
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Alginic acid
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How is the aluminum and magnesium found in antacids cleared from the body?
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Renally
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What is the mechanism of action for the treatment of GERD with H2 Receptor Antagonists?
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H2RAs decrease gastric acid secretion by inhibiting the effect of histamine on the histamine-2 receptor of parietal cells.
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What is the onset of action and the duration of action for the effect of H2RAs on gastric parietal cells?
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Onset of action: 30 to 45 min; Duration: 4 to 10 hrs.
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What percentage of patients experience symptomatic improvement of erosive esophagitis with H2RAs vs. PPIs?
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Symptomatic improvement is seen in about 60% of patients with H2RAs, 83% with PPIs.
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What percentage of erosive esophagitis patients treated with H2RAs versus PPIs are found to have healing when examined endoscopically?
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The endoscopic healing rate is 50% with H2RAs, 78% with PPIs.
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List six common side effects of H2RAs. In what patient population are they most likely to occur?
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Headache, somnolence, fatigue, dizziness, constipation, and diarrhea. Side effects are most common in the elderly.
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Which H2RA is particularly troublesome with respect to drug interactions and what is the nature of these interactions?
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Cimetidine inhibits many CYP450 enzymes, leading to drug interactions with a wide variety of drugs.
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What is the mechanism of actions for the treatment of GERD with PPIs?
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PPIs block gastric acid secretion by inhibiting gastric H+/K+-ATPase in gastric parietal cells.
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What is the onset of action and the duration of action for the treatment of GERD with PPIs? Why does it take several days for PPIs to provide full relief?
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Onset of action: 2 to 3 hrs; Duration of action: 12 to 24 hrs. It may take several days (1 to 4 days) for PPIs to provide full relief because PPIs only inhibit actively secreting pumps and not all pumps are active at a given time.
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Which two CYP enzymes are predominantly responsible for the metabolism of PPIs?
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CYP 2C19 & 3A4
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List six common side effects of PPIs.
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Headache, dizziness, somnolence, diarrhea, constipation, nausea
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Which class of medication for the treatment of GERD carries an increased risk of fractures with longterm use?
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PPIs
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What vitamin and mineral deficiencies are of concern with longterm use of PPIs?
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Vitamin B12 deficiency, hypomagnesemia, and malabsorption of iron.
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What is a potentially serious cause of diarrhea in patients on longterm PPI treatment (how must it be treated)?
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Clostridium difficile bacteria (requires antibiotic treatment)
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How is calcium supplement absorption effected by PPIs?
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Calcium carbonate requires an acidic environment for optimal absorption, so PPIs inhibit CaCO3 absorption. Calcium citrate, on the other hand, is absorbed more readily by patients taking PPIs.
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Which PPI is said to have the greatest number of drug interactions? Which one is said to have the least?
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Omeprazole is said to have the greatest number of interactions and pantoprazole is said to have the least.
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At what time, relative to a meal, should a PPI be administered for the treatment of GERD?
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30 to 60 min prior to a meal.
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Which is superior for heartburn resolution, H2RAs or PPIs?
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PPIs
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Is a standard dose PPI superior to a low dose PPI for heartburn resolution? Is a standard dose H2RA superior to a low dose H2RA for heartburn resolution?
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No and no. Neither PPIs nor H2RAs show a dose-response curve for the treatment of heartburn.
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Which is superior for treatment of esophagitis, H2RAs or PPIs?
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PPIs
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Is a standard dose of a PPI superior to a low dose for the treatment of esophagitis?
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Yes.
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What are two promotility agents used in select patients as an adjunct to acid suppression therapy in the treatment of GERD?
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Metoclopramide & Bethanecol
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What are the side effects of promotility agents?
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Drowsiness, irritability, & extrapyramidal effects
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