Download GERD template word AK 1013

Condition/Case
GERD.:Gastro Esophageal Reflux Disease
Goals of
Therapy
1 Relieve symptoms, particularly heartburn
2 Promote healing of esophagitis.
3 Prevent complications s/a stricture formation, bleeding or progression to Barrett’s epithelium.
4 Prevent recurrences.
5 Improve quality of life. Education around diet and lifestyle factors that can contribute.
Tx Options
(drug classes)
- consider
effectiveness,
toxicity, S/E,
convenience
Rx
Pro
Con
Choose 1 agent:
indications, S/E, CI
1 PPI - 1st line
Treats Sx AND
Slow acting- not for prn. Choose least expensive:
Proton Pump Inhibitor esophagitis.
Omeprazole
I:
Best option for
AE: D/flatulence, abd.
Omeprazole
SE:D/Flatulence, abd
prevention of
pain
recurrences.
Rebound on stopping 15% pain. Rebound Sx on
Note:
stopping
Management 2 H2RAs
Inexpensive. OTC
Less effective at
Choose least expensive:
options for mild Sx
improving Sx and QOL s/a Ranitidine
algorithm pg H2 Receptor
Antagonists
then PPI in Mod/Severe AE: D/C/HA/fatigue,
805
confusion (elderly and
Considered fairly safe Less effective at
Ranitidine.
poor renal function),
and
effective
class
of
preventing
recurrences
MILD:
cardiac effects, rash
drugs.
then
PPI
non-pharm
3 Antacid
Fast acting
Does not treat esophagitis I: Acute symptoms, fast
antacid
Tums
acting.
alginate
Neutralizes acid quickly. Does not prevent
non-Rx
*acute option
This form also provides recurrences.
H2RA
calcium
4 Alginate
Alginate helps prevent Caution renal dysfunction.
Moderate/Se
esophagitis by trapping Does not treat esophagitis Caution: significant
vere:
Alginate/magnesium acid in stomach.
magnesium conent.
Renal clearance.
PPI 2-4wk carbonate (Gaviscon
tablets)
Fast
acting
PRN
Does
not
prevent
assessprescription, OTC.
recurrences.
continue 15
Natural
Option:
Rare
to
have
side
effects
More costly therapy2X/day 4-8
DGL
PRN
with
with
these
remedies.
patient must pay.
wk. Tailor
probiotics and slippery Promotes healing of
potential for more poor
dose to stop
elm bark.
esophagitis and
compliance- 3 remedies
OR longterm
dyspepsia management versus one.
use.
What I would Rx (including d/c of Rx) PPI X 4 wk then re-assess. (upto 12 weeks therapy)
Date
Name and address of patient
Omeprazole 20mg daily AC breakfast oral.
Sig: once daily.
Mitte: 56
Refills: 2
Dr. ND Reg#XXXX
Pro: can increase dose if needed (recommended range 20 - 40mg qd), once daily dosing, inexpensive, long track
record.
Con: Adverse effects of diarrhea, flatulence and abdominal pain. Possible decrease efficacy of drugs requiring acid
environment for dissolution/absorption.
NOTE: Low dosing decreases these possibilities.
Monitoring
What to monitor?
When?
Who is monitoring?
PHARM GERD
AK 1013
Parameters
dyspepsia improvement
Quality of Life
Frequency of symptoms
Lifestyle modifications
Food or lifestyle aggravations
EFFICACY
&
TOXICITY Adverse effects: headache,
nausea, diarrhea, rash.
With prolonged PPI use:
-Fractures (.3%
vertebral/0.025% hip if real)
-pneumonia (if real 0.25%)
-c.difficile (1.5% in hospital,
0.1% community)
-B12 + Iron deficiency
(theoretical only)
Colorectal Cancer? (low
probability- no evidence)
Relapse of condition
Drug interactions (PPI)
Misc
2-4 weeks and again 4-8 weeks Patient - if not improving :relater.
assess diagnosis and treatment.
2 weeks, sooner if not tolerating Patient reports to doctor, doctor
drug (within 2 weeks)
asks specifically: diarrhea,
flatulence, abdominal pain.
Change drug if necessary or try
lower dose.
Be aware of these concerns as
possibilities.
Patient returns if symptoms
return.
On adding drug esp.
Clopidogrel
Patient. (15% can have rebound
dyspepsia)
Patient and doctor. Note suspected
risk is 0%
Rx Changes
After 2-4 weeks if no improvement consider twice daily PPI. If still no response- investigate with
endoscopy or pH/motility studies. Continued treatment with PPI if effective for 6-12 weeks. Tailor
dose when coming off to reduce rebound dyspepsia. Some patients need longterm low dose PPI.
Other Tx
Try non-drug measures first, and continue even if drug is needed. such as: avoidance of foods that
worsen symptoms, avoid lying down directly after meals, DO eat smaller meals, raise the head of
the bed 4-6 inches, stop smoking, lose weight.
If lower GI complaints as well, as seen in 33% of dyspepsia cases, treating IBS may reduce
dyspepsia and improve QOL (Quality of life).
Probiotics as co-therapy.
Misc
r/o gastric or esophageal cancer (<2% with dyspepsia): >50yo, abdominal mass, alarm Sx
(vomiting, bleeding, dysphagia, anemia or weight loss). WITH endoscopy
Cardiac causes of Sx ruled out.
PHARM GERD
AK 1013
RED
FLAGS
ASA/NSAID USE: common cause including: low dose ASA for cardio-protection. --> Stop NSAID
where possible, tx PPI 4-8wk.
LIST
DRUG
INTERACTIONS
ETC. ASSOC
WITH THE
CONDITION
In severe cases DO NOT use on-demand therapy.
PHARM GERD
DON’T TREAT A SIDE EFFECT OF A DRUG WITH ANOTHER DRUG! (UNLESS
ABSOLUTELY NECESSARY).
Other drugs that can cause or aggravate dyspepsia include: bisphosphonates (alendronate,
etidronate, risedronate), tetracyclines, calcium-channel blockers (amlodipine, diltiazem, verapamil),
NSAIDS, theophylline, tricyclic antidepressants (clomipramine, desipramine, imipramine, doxipin,
nortryptaline). Try avoidance first. These drugs impair esophageal motility and lower
esophageal sphincter tone.
AK 1013