Self Care Exam Iii Heartburn

Front 1

Heartburn

Back 1

uncomfortable feeling of warmth or burning that arises from the lower chest and moves upward to the neck or throat

Front 2

postprandial heartburn

Back 2

occurs after eating

Front 3

nocturnal heartburn

Back 3

occurs while sleeping

Front 4

simple heartburn

Back 4

typically mild, infrequent, episodic, and often is related to diet or lifestyle

Front 5

frequent and persistant heartburn (2 or more days a week for 3 or more months)

Back 5

is the most common symptom of gastroesophageal reflux disease

Front 6

GERD

Back 6

not self care condition, symptoms or muscoal damage produced by abnormal reflux of gastric contents into the esophagus.

Front 7

dyspepsia

Back 7

upper abdominal discomfort which may include upper abdominal pain, bloating, early satiety (feeling of fullness), nausea or belching

Front 8

other words for dyspepsia

Back 8

upset stomach, indigestion, nervous stomach

Front 9

causes for dyspepsia

Back 9

May be related to food or other diseases such as peptic ulcer disease (PUD), GERD, gastroparesis, or irritable bowel syndrome

Front 10

dyspepsia and decreased GI motility-

Back 10

gastroparesis, sometimes seen in patients who have had diabetes.

Front 11

non-ulcer dyspepsia

Back 11

symptoms like you have ulcer, testing that there is no ulcer present

Front 12

treatment goals for heartburn and dyspepsia

Back 12

Alleviate symptoms
Prevent recurrent symptoms
Improved quality of life
Prevent complications

Front 13

selected risk factors for heartburn
dietary-

Back 13

Fatty/ spicy foods
Chocolate
Peppermint, spearmint
Alcohol
Caffeine
Carbonated beverages and citrus juices

Front 14

selected risk factors for heartburn
life style-

Back 14

Smoking
Obesity
Stress
Tight-fitting clothes
Supine position

Front 15

selected risk factors for heartburn
diseases-

Back 15

gastroparesis, PUD

Front 16

selected risk factors for heartburn
pregnancy

Back 16

releasing estrogen and progesterone, baby pushing on stomach

Front 17

selected risk factors for heartburn
medications

Back 17

Bisphosphonates
(Alendronate (Fosamax), risedronate (Actonel) ibandronate(Boniva))--
Aspirin
NSAIDs
Narcotic analgesics

Front 18

exclusions for self treatment
** alarm

Back 18

Dysphagia-difficulty swallowing
Odynophagia –painful swallowing
Upper GI bleeding-
Vomiting blood or black material
Blood in stools or black, tarry stools
-Anemia
Unexplained weight loss

Front 19

alarm symptoms can lead to:

Back 19

Barretts esophagus: precancerous condition, acid damage continues it can go to esophageal cancer

Front 20

additional exclusions for self treatment

Back 20

Any “Alarm Symptoms”
Frequent heartburn for more than 3 months
Heartburn or dyspepsia while taking H2RA or PPI
Heartburn that continues after 2 weeks of treatment
Severe symptoms
Nocturnal heartburn
Chronic hoarseness, wheezing, coughing, or choking
Continuous nausea, vomiting, or diarrhea
Chest pain with sweating, pain radiating to shoulder, arm, neck, or jaw and shortness of breath
Pregnancy
Nursing mothers
Children younger than 12 years

Front 21

non pharmacologic
dietary and lifestyle changes:

Back 21

Little evidence to support most measures
Individualize to patient’s dietary and lifestyle patterns
Most patients will still require pharmacologic therapy

Front 22

non pharmacologic therapy

Back 22

Avoid food, beverage, medication triggers
Avoid eating large meals
Stop smoking
*Lose weight if overweight
Avoid lying down within 3 hours after meal
*Elevate head of bed using blocks or foam pillow wedge
Do NOT stack regular pillows—worsen symptoms

Front 23

pharmacologic therapy

Back 23

Antacids
Histamine 2-Receptor Antagonists
Proton Pump Inhibitors
Bismuth Subsalicylate

Front 24

characteristics of OTC heartburn medications:
Antacids

Back 24

onset: <5 minutes
duration: 20 to 30 minutes
symptom relief: excellent

* if taken with food, lasts longer

Front 25

characteristics of OTC heartburn
medications:
H2RA's

Back 25

onset: 30 to 40 minutes
duration: 4 to 10 hours
symptom relief: excellent

Front 26

characteristics of OTC heartburn medications:
H2RA and Antacids

Back 26

onset: <5 minutes
duration: 8 to 10 hours
symptom relief: excellent

Front 27

characteristics of OTC heartburn medications:
PPI's

Back 27

onset: 2 to 3 hours
duration: 18 to 24 hours
symptom relief: superior

* full effect takes 1 to 4 days

Front 28

Antacids

Back 28

Products: Contain calcium carbonate, aluminum, magnesium, and/ or sodium bicarbonate

Front 29

tums

Back 29

calcium carbonate

Front 30

rolaids

Back 30

Calcium Carbonate + Magnesium hydroxide

Front 31

mylanta, maalox

Back 31

Aluminum hydroxide + Magnesium hydroxide

Front 32

alka-seltzer

Back 32

Sodium bicarbonate

Front 33

antacid indication

Back 33

: mild, infrequent heartburn or dyspepsia

Front 34

antacid MOA

Back 34

neutralize gastric acid

Front 35

antacids
drug interactions

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tetracyclines, quinolones, levothyroxine, ketoconazole, itraconazole, iron

** separate by 2 hours

Front 36

antacids
warnings:

Back 36

Magnesium: may accumulate in renal disease
Aluminum: hypophosphotemia, may accumulate in renal disease
Calcium carbonate: hypercalcemia, renal calculi
Sodium bicarbonate: fluid overload
Milk-alkali syndrome

Front 37

milk alkali syndrome

Back 37

: hypocalcaemia (high Ca), metabolic acidosis, renal failure- caused by ingesting a lot of Ca + alkali such as antacid

Front 38

renal calculi

Back 38

renal stones

Front 39

antacid
side-effects

Back 39

Magnesium: diarrhea
Aluminum: constipation
Calcium carbonate: belching, flatulence, constipation, possible acid rebound
Sodium bicarbonate: belching, flatulence

Front 40

antacid
dosing

Back 40

Product specific, take at onset of symptoms and usually may repeat in 1-2 hours

Front 41

FDA warns of Maalox mix up

Back 41

FDA has several reports of serious adverse events
Similar packaging and Maalox name
Different ingredients and different symptoms
Maalox Total Relief contains bismuth subsalicylate

** Bleeding, child, aspirin allergy: cannot take bismuth subsalicylate.- Not antacid

Front 42

OTC H2RA's
products:

Back 42

ranitidine (Zantac), famotidine (Pepcid AC), cimetidine (Tagamet HB), nizatidine (Axid)
Combination product: famotidine plus calcium carbonate and magnesium (Pepcid Complete)

Front 43

OTC H2RA's
indication

Back 43

mild-to-moderate, infrequent heartburn or dyspepsia

Front 44

OTC H2RA's
MOA

Back 44

Competitively inhibit the binding of histamine to receptors on gastric parietal cells (H2 receptors) to reduce gastric acid secretion

Front 45

OTC H2RA's
drug interactions

Back 45

ketoconazole, itraconazole, iron, calcium carbonate
Cimetidine has the most interactions (P450 3A4, 2D6, 1A2, and 2C9 inhibitor)
Cimetidine inhibits metabolism of warfarin, phenytoin, theophylline

Front 46

OTC H2RA's
warnings:

Back 46

caution in renal failure, elderly

Front 47

OTC H2RA's
side effects

Back 47

well tolerated
GI upset, dizziness, headache, rare thrombocytopenia (low platelets)

Front 48

OTC H2RA's
dosing

Back 48

Take at onset of symptoms or 30-60 minutes before meal when heartburn anticipated
Do not take more than twice daily
Do not use for more than 14 days without physician advice

Front 49

proton pump inhibitors
products:

Back 49

omeprazole (Prilosec OTC), lansoprazole (Prevacid 24HR)
Combination product: omeprazole + sodium bicarbonate (Zegerid OTC)

** most potent

Front 50

proton pump inhibitors
indications

Back 50

Drug of choice for frequent heartburn or for patients who do not respond to H2RAs

Front 51

proton pump inhibitors
MOA

Back 51

Suppress gastric acid secretion by inhibiting the hydrogen potassium ATPase (proton pump)
More potent and longer acting than H2RAs or antacids

Front 52

proton pump inhibitors
drug interactions

Back 52

warfarin, phenytoin, diazepam, ketoconazole, itraconazole, iron, calcium carbonate
New concern for interaction with clopidogrel (Plavix)

Front 53

proton pump inhibitors
warnings

Back 53

Symptom relief does not preclude presence of gastric cancer

Front 54

proton pump inhibitors
side effects

Back 54

diarrhea, constipation, headache

Front 55

what is the best calcium supplement for a person on PPI's

Back 55

calcium citrate.

Usually recommend Ca Carbonate, but it needs acid to be absorbed. Ca Citrate does not need acid to be absorbed

Front 56

PPI may make Plavix (anti platelet drug, take after stroke, stent put in) not work as well.
Could mask symptoms of stomach cancer.

Back 56

true

Front 57

proton pump inhibitor
dosing

Back 57

Take once daily 30-60 minutes before meal (usually breakfast)
Do not treat for more than 14 days
May repeat course if symptoms return after 4 months

Front 58

proton pump inhibitor
long term side effects

Back 58

Vitamin B12 malabsorption?
Increased risk of Clostridium difficile infection?
Increased risk of community-acquired pneumonia?
Calcium malabsorption/ hip fracture risk?
Iron malabsorption?

** no conclusive evidence

Front 59

should patients take an H2RA in combination with PPI's if monotherapy not working?

Back 59

Self Care: no, if symptoms on 1 agent then refer to physician.
Vast majority: No, but some evidence say it may be okay to take these in combo. H2blocker at night may help to alleviate symptoms.

Front 60

bismuth subsalicylate (pepto bismol)
indications

Back 60

heartburn
dyspepsia

Front 61

bismuth subsalicylate
MOA

Back 61

antiinfective actions and direct mucosal protective effect

Front 62

bismuth subsalicylate
drug interactions

Back 62

tetracyclines, quinolones, anticoagulants, NSAIDs/ aspirin

Front 63

bismuth subsalicylate
warnings

Back 63

ulcer or bleeding disorder, aspirin allergy, ringing in ears, avoid in children < 12 years, Reye syndrome, contraindicated in pregnant or nursing women

Front 64

bismuth subsalicylate
side effects

Back 64

harmless discoloration of stool and tongue

Front 65

what is in children's pepto?

Back 65

calcium carbonate

Front 66

case study

Back 66

see slides 30 thru 34

Front 67

heartburn and dyspepsia in the elderly

Back 67

More likely to develop complications 
More likely to take Rx medication that contributes to heartburn and dyspepsia
More likely to take medications that interact with antacids, H2RAs, PPIs
Consider renal function
Consider side effects

*cimetadine = confusion in elderly

Front 68

heartburn and dyspepsia in children

Back 68

Refer children under 12 years to primary care provider
OTC antacids are labeled for children > 12 yrs
OTC H2RAs are labeled for children > 12 yrs
OTC PPIs are labeled for patients > 18 yrs

Front 69

heartburn and dyspepsia in pregnancy

Back 69

Refer pregnant women with moderate-to-severe heartburn to primary care provider
Mild, infrequent heartburn may respond to diet and lifestyle modification

H2RA: B (moderate heartburn), PPI: C – not recommended for self care.
H2RA’s shouldn’t be used longer than 2 weeks for self care, but they can be used longer (it won’t be self care though)