* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download GERD template word AK 1013
Neuropsychopharmacology wikipedia , lookup
Compounding wikipedia , lookup
Polysubstance dependence wikipedia , lookup
Electronic prescribing wikipedia , lookup
Psychedelic therapy wikipedia , lookup
Drug design wikipedia , lookup
Pharmacognosy wikipedia , lookup
Drug discovery wikipedia , lookup
Neuropharmacology wikipedia , lookup
Pharmaceutical industry wikipedia , lookup
Prescription drug prices in the United States wikipedia , lookup
Prescription costs wikipedia , lookup
Psychopharmacology wikipedia , lookup
Pharmacokinetics wikipedia , lookup
Dydrogesterone wikipedia , lookup
Discovery and development of proton pump inhibitors wikipedia , lookup
Drug interaction wikipedia , lookup
Theralizumab wikipedia , lookup
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