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GERD

Salman Bin AbdulAziz University

College Of Pharmacy

Therapeutics II PHCL 430

Ahmed A AlAmer

PharmD

Email:Ahmedadel.pharmd@gmail.com

• A .W 75-year-old man with a 3-year history of severe GERD symptoms and Parkinson disease has been taking lansoprazole 30 mg 2 times/day for 5 months.

• He has initiated proper nonpharmacologic measures, including elevating the head of his bed, reducing fat intake and portion size, avoiding tight-fitting clothes, and losing weight.

• Because he continues to have daily heartburn symptoms, he is referred for endoscopy, which reveals normal-appearing mucosa and no structural abnormalities.

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Define GERD !

A condition which develops when reflux of stomach contents causes troublesome symptoms and/or complications

• A 75-year-old man with a 3-year history of severe GERD symptoms?? and Parkinson disease has been taking lansoprazole 30 mg 2 times/day for 5 months.

• He has initiated proper nonpharmacologic measures, including elevating the head of his bed, reducing fat intake and portion size, avoiding tight-fitting clothes, and losing weight.

• Because he continues to have daily heartburn symptoms, he is referred for endoscopy, which reveals normal-appearing mucosa and no structural abnormalities.

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What are the symptoms of GERD ?

Typical symptoms Extraesophageal symptoms (formerly referred to as atypical)

Heartburn (pyrosis) Regurgitation Acidic taste in the mouth

Chronic cough, asthma-like Symptoms recurrent sore throat, laryngitis/hoarseness, dental enamel loss Non cardiac chest pain; sinusitis/pneumonia/bronchitis/otitis media are less common atypical symptoms.

Symptoms of GERD

Alarm symptoms

troublesome dysphagia odynophagia, bleeding, weight loss, choking, chest pain, and epigastric mass

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Questions

• Pyrosis is ……………….

• Regurgitation and Acidic taste in the mouth are ………. Symptoms of GERD ( typical /atypical /alarm )

• GERD is ………………………………….

• recurrent sore throat, laryngitis/hoarseness, dental enamel loss are ……………. Symptoms of GERD ( typical /atypical /alarm )

• troublesome dysphagia odynophagia, bleeding are ………….. Symptoms of GERD ( typical /atypical /alarm )

• What can aggravate M.W condition ?

Aggravating factors in GERD

I. Recumbency (gravity) II. increased intra-abdominal pressure III. Reduced gastric motility IV. decreased lower esophageal sphincter (LES) tone V. direct mucosal irritation

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Questions

• Mention 3 aggravating factors in GERD?

True or false

• (gravity) is considered to be an aggravating factor for GERD ?

• increased lower esophageal sphincter (LES) tone is an aggravating factor for GERD ?

• increased intra-abdominal pressure is a complication for GERD ?

• Long-term complications of GERD are ?

I. Esophageal erosion II. strictures/obstruction III. Barrett esophagus, IV. and reduction in patient’s quality of life

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Complete

• ….………and ………..…. are some complications of GERD

• A .W 75-year-old man with a 3-year history of severe GERD symptoms and Parkinson disease has been taking lansoprazole 30 mg 2 times/day for 5 months.

• He has initiated proper nonpharmacologic measures, including elevating the head of his bed, reducing fat intake and portion size, avoiding tight-fitting clothes, and losing weight.

• Because he continues to have daily heartburn symptoms, he is referred for endoscopy??????, which reveals normal-appearing mucosa and no structural abnormalities.

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Diagnosis

I. Based on Symptoms ? ….in uncomplicated cases

Symptoms do not predict the degree of esophagitis or complications secondary to GERD, if present.

Patients presenting with extraesophageal symptoms should be assessed on a case-by-case basis to consider the need for referral or alternative/invasive testing.

Cardiac etiologies (ischemic) should be considered and explored before arriving at a diagnosis of reflux chest pain syndrome.

it is reasonable to assume a diagnosis of GERD in patient who respond to initial acid-suppressive therapy, particularly proton pump inhibitors (PPIs).

Diagnosis

II. Endoscopy ……….

Choice to identify Barrett esophagus (with biopsy) or complications of GERD

97% specific for the diagnosis of GERD

most patients with typical/atypical symptoms will have normal-appearing esophageal mucosa on endoscopy

When to use endoscopy ?

I. Age > 45 years, II. Patient with alarm symptoms (particularly

troublesome dysphagia III. refractory to initial treatment, as well as in those

with a preoperative assessment or possibly when extraesophageal symptoms are present

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Diagnosis

II. Manometry ……….

Used to evaluate peristaltic function of the esophagus in patients with normal endoscopic findings

Diagnosis

II. pH testing ……….

The main outcome measure of esophageal pH monitoring is the percentage of time the pH value is less than 4 in a 24-hour period.

Ambulatory pH testing is useful in the following clinical situations: i. Patients with no mucosal changes on endoscopy and normal manometry who have continued symptoms (both typical and atypical) ii. Patients who are refractory to therapeutic doses of appropriate pharmacologic agents iii. Monitoring of reflux control in patients with continued symptoms on drug therapy c. Sensitivity/specificity of 96% reported d. The PPIs should be withheld for 7 days before pH testing, if possible, for the most accurate results.

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True or false

• it is reasonable to assume a diagnosis of GERD in patient who respond to initial acid-suppressive therapy, particularly proton pump inhibitors (PPI) ?

• Symptoms predict the degree of esophagitis or complications secondary to GERD, if present. ?

• most patients with typical/atypical symptoms of GERD will have abnormal-appearing esophageal mucosa on endoscopy

Complete

• Endoscopy is the choice to identify ………………………… GERD

• most patients with typical/atypical symptoms of GERD will have …………………………..on endoscopy

• Endoscopy is ……….. (specific /not specific ) for diagnosis GERD

• Mention 3 indications for the use of endoscopy in patient with GERD ?

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• A 75-year-old man with a 3-year history of severe GERD symptoms?? and Parkinson disease has been taking lansoprazole ??? 30 mg 2 times/day for 5 months.

• He has initiated proper nonpharmacologic measures, ???? including elevating the head of his bed, reducing fat intake and portion size, avoiding tight-fitting clothes, and losing weight.

• Because he continues to have daily heartburn symptoms, he is referred for endoscopy, which reveals normal-appearing mucosa and no structural abnormalities.

Treatment

• Treatment options for GERD

Nonpharmacologic interventions/lifestyle modifications

Pharmacologic therapies

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Nonpharmacologic interventions/lifestyle modifications

A. Dietary modifications in patients whose symptoms are associated with certain foods or drinks

i. Avoid aggravating foods/beverages; some may reduce LES pressure (alcohol, caffeine, chocolate, citrus juices, garlic, onions, peppermint/spearmint) or cause direct irritation (spicy foods, tomato juice, coffee). ii. Reduce fat intake (high-fat meals slow gastric emptying) and portion size. iii. Avoid eating 2–3 hours before bedtime. iv. Remain upright after meal

B. Weight loss for overweight or obese patients C. Reduce/discontinue nicotine use in patients who use tobacco products (affects LES). D. Elevate the head of the bed (6–8 in.) if reflux is associated with recumbency E. Avoid tight-fitting clothing (decreases intra-abdominal pressure). F. Avoid medications that may reduce LES pressure, delay gastric emptying, or cause

direct irritation: α-Adrenergic antagonists, anticholinergics, benzodiazepines, calcium channel blockers,

estrogen, nitrates, opiates, tricyclic antidepressants, theophylline, NSAIDs, and aspirin

Complete

• Generally , Nonpharmacologic treatment such as dietary modifications of GERD options include …………………

• ………… fat intake as dietary modification for GERD patient ( reduce /increase)

• ………… eating 2–3 hours before bedtime ( avoid/ encourage) as dietary modification for GERD patient

• Remain………….after meal as dietery modification for GERD patient (upright /lay down )

• Reduce/discontinue nicotine use in patients who use tobacco products (affects LES). ( T/F)

• In GERD patient Elevate the head of the bed (6–8 in.) if reflux is associated with recumbency (T/F)

• Examples of medications that causes direct gastric irritations ??

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1

aluminum hydroxide, magnesium hydroxide and simethicone.

contain the anti-refluxant alginic acid, which forms a viscous layer on top of gastric contents to act as a barrier to reflux

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Symptomatic relief of GERD

2

Healing of erosive esophagitis or treatment of patients presenting with moderate to severe symptoms or complications

3

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questions

• Examples of OTC PPI

• Examples of OTC Anti H2 receptor

• Examples of antacids

• Ranitidine 75 mg BID (OTC) or Omeprazole 20 mg (OTC) Once daily can be used for ………………(Intermittent, mild heartburn or Symptomatic relief of GERD or , Healing of erosive esophagitis)

• Patient with mild symptomatic GERD can be given a prescribed ranitidine 150 mg BID (6-12 weeks )? (T/F)

• Patient with severe symtomatic GERD can be given a prescribed omeprazole 20 mg once daily (4-8 weeks) ? (T/F)

• Goviscon contain ……………………………………

• Duration of treatment of mild symptomatic GERD with anti H2 receptor is ……………….

• Duration of treatment of severe to moderate symptomatic GERD with PPI is ………

• Duration of treatment for Healing of erosive esophagitis with PPI is …………. And duration with high dose of H2RA is ……….. ….

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True or false

• PPIs are more effective than histamine2-receptor antagonists (H2RA) ? True

•All PPIs are similar in efficacy when used for patients with esophageal GERD symptoms.

True

•Maintenance therapy is appropriate for patients with esophagitis in whom PPIs have been effective Titration to the lowest effective dose is recommended.

True

Drugs

Antacids

• Calcium-, aluminum-, and magnesium-based products are available OTC in a wide variety of formulations (capsules, tablets, chewable tablets, and suspensions).

• Side effects

Constipation (aluminum), (magnesium), diarrhea Accumulation of aluminum/magnesium in renal disease with repeated dosing Drug interactions: Chelation (fluoroquinolones, tetracyclines), reduced absorption because of increases in pH (ketoconazole, itraconazole, iron, atazanavir, delavirdine, indinavir, nelfinavir) or increases in absorption leading to potential toxicity (raltegravir, saquinavir)

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Drugs

H2RAs ( (cimetidine, ranitidine, famotidine, nizatidine))

Side effects: – Headache – Somnolence – Fatigue – Dizziness – Either constipation or diarrhea

• Cimetidine may inhibit metabolism of some drugs (e.g., theophylline, warfarin, phenytoin).

• They are equally effective; selection of agent based on differences in pharmacokinetics, safety profile, and cost

• Elderly patients and those with reduced renal function are more at risk. • Prolonged cimetidine use is associated with rare development of gynecomastia.

Drugs • PPIs (dexlansoprazole, esomeprazole, lansoprazole, omeprazole, pantoprazole,

– Side effects:

• Headache

• Dizziness

• Somnolence

• Diarrhea

• Constipation

• Nausea

• Vitamin B12 deficiency

– May facilitate Clostridium difficile infection during acid suppression.

– Lansoprazole, esomeprazole, and pantoprazole available in IV formulations, but are not more effective than oral preparations and are more expensive.

• New FDA labeling for PPIs as of May 2010 stating that PPIs may increase the risk of hip and spine fracture

• Patients should take oral PPIs in morning 15–30 minutes before breakfast; dexlansoprazole can be taken without regard to meals.

• If dosed twice daily, second dose should be taken 10–12 hours after morning dose and prior to meal or snack not bed time

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• Side effects of mg containing antacids is ………… while Aluminum containing antacids can cause ……………….

• Antacids with fluoroquinolone can form ……………………..

• Cimetidine may inhibit metabolism of some drugs (e.g., warfarin) (T/F)

• Prolonged cimetidine use is associated with rare development of مهم) ..…………………………

• IV PPI . Include …………………………………………………..

• PPI can cause vitamin ………….. Deficiency

• New FDA label for PPI stating that PPIs may …………………………of hip and spine fracture

Back to the case

• A .W 75-year-old man with a 3-year history of severe GERD symptoms and Parkinson disease has been taking lansoprazole 30 mg 2 times/day for 5 months.

• He has initiated proper nonpharmacologic measures, including elevating the head of his bed, reducing fat intake and portion size, avoiding tight-fitting clothes, and losing weight.

• Because he continues to have daily heartburn symptoms, he is referred for endoscopy, which reveals normal-appearing mucosa and no structural abnormalities.

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Which one of the following is the best course of action for this patient?

• A. Add metoclopramide 10 mg 4 times/day and reassess in 3 months.

• B. Educate about the proper use of lansoprazole and refer for manometry.

• C. Add metoclopramide 10 mg 4 times/day and refer for surgical intervention.

• D. Add famotidine 20 mg/day at bedtime and reassess in 4 months.

Avoid because of Parkinson disease can cause EPS

Combination is not preffered