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ahmed ibrahim fahmy

on 24 April 2013

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Transcript of GERD OTC

OTC of the GIT Nausea
& vomiting GERD
& peptic ulcer Anorectal
disorders Diarrhea Constipation Intestinal gas
& dyspepsia Nausea & vomiting GERD Topics to be discussed 1-Introduction 2-Etiology 3-When to refer 4-Treatment algorithm 5-Summary & Case What it is GERD ? -Heartburn (Pyrosis) is a burning sensation that usually arises from the substernal area (lower chest)
and moves up toward the neck or throat -Postprandial heartburn usually occurs within 2 hrs after eating or when bending over or lying down -Nocturnal heartburn occurs during sleep and often awaken the person -Heart burn that is frequent (2 or more days a week) and persistent (3 or more months ) is the most common typical symptom of GERD -60 % to 70 % suffer from heartburn even when the oesopheageal injury is not present
(nonerosive gasteroesophageal reflux disease : NERD) -More than 60 million adult Americans suffer from heartburn at least once a month and over 25 million experience heartburn daily. Complications : -10-15% with GERD will develop Barrett’s esophagus -1-10% of those with Barrett’s will develop adenocarcinoma over 10-20 years Etiology : -the most common mechanism for acid reflux is transient relaxation of the LES. -other mechanisms : -increased intra-abdominal pressure (strain induced reflux) -baseline Low LES pressure -delayed gastric emptying -Medication use (ex : CCBs) -Hiatal hernia -poor esophageal acid clearance (dysmotility , scleroderma , decreased salivary production - the refluxate is cleared from the esophagus by : 1-peristaltic contractions 3-neutralization by the bicarbonate in the saliva 2-gravity -the esophageal epithelium is not as tolerant as that of the stomach to repetitive exposure of gastric acid -the refluxed acid may also damage the larynx (laryngitis) , respiratory system (asthma ) -the lower esophageal sphincter (LES) serves as the primary anti-reflux barrier by preventing back flow of stomach contents Mechanism of GERD : When to refer ? -frequent heartburn for more than 3 months -vomiting up blood or black material or black tarry stool -children younger than 12 yrs old -chronic hoarseness , wheezing , coughing or choking -Dysphagia -odynophagia -unexplained weight loss -Early satiety -continuous nausea , vomiting or diarrhea -OTC drugs not working -2 weeks of OTC PPI or H2RA with no resolution Non-cardiac chest pain (NCCP) The heart and the esophagus are located in the chest cavity in close proximity & They receive very similar nerve supply. Thus, pain arising from either organ travel through the same nerve sensory fibers
to the brain. the most common cause is GERD OTC treatment algorithm Life style modification and diet change 1-Head elevation : Head of bed elevation (10 - 20 cm) and avoidance of meals 2 – 3 hr before bedtime should be recommended for patients with nocturnal GERD (ACG guidelines 2013) 3 randomized controlled trials have demonstrated 2-Weight loss : According to ACG guidelines 2013 There is a definite relationship between GERD and obesity.
Several meta-analysis suggest an association between body mass index (BMI) , waist circumference, weight gain and the presence of symptoms and complications of GERD including ERD and Barrett ’ s esophagus Weight gain even in subjects with a normal BMI has been associated
with new onset of GERD symptoms there has been a well-documented association between BMI and carcinoma of the esophagus and gastric cardia 3-Diet change : Several foods are believed to be direct esophageal irritants: citrus juices, carbonated beverages, coffee and caffeine, chocolate, spicy foods, fatty foods, or late evening meals. (ACG)

However, no randomized controlled trials to support recommendations to avoid or minimize these foods. (ACG )
Thus Individualized dietary modification is preferred tobacco and alcohol cessation are not recommended to improve GERD symptoms according to 4 trials there cessation were not shown to raise LESP, improve esophageal pH, or improve GERD symptoms. (ACG ) 4- Avoid medications that lower LES pressure
or irritate the esophagus : Medications that lower LES pressure should be avoided in patients with symptoms of GERD : Medications that irritate the esophagus : NSAIDS, ferrous sulfate , bisphosphonates The patient should be advised to consult with his prescriber about drugs that may make GERD symptoms more troublesome -Calcium channel blockers -Beta agonists -Alpha adrenergic agonists -Theophylline -Nitrates -Narcotics -Benzodiazepines -Anticholinergics -PDE 5 inhibitors Reflux pain: Cardiac pain: -burning, worse on bending, stooping or lying down
-Seldom radiates to the arms
-Worse with hot drinks or alcohol
-Relieved by antacids -Gripping or crushing
-Radiates to neck or left arm
-Worse with exercise
-Accompanied by dyspnea improvement in GERD symptoms and esophageal pH values with head of bed elevation using blocks or foam wedges Drugs used in the treatment of GERD Antacids , H2RAs ,PPIs ,Prokinetics The selection of the OTC drug should be based on : -frequency -duration -severity of symptoms -cost -drug drug interaction -patient’s preference 1-Antacids : -the use of antacids is limited by their short duration when taken on empty stomach but the duration may be prolonged for several hours if taken after a meal -for more prolonged relief of symptoms H2RAs is preferred to an Antacid -Liquid antacid usually have a faster onset than tablets because they are already dissolved and provide maximal surface area for action -dosing of antacids may be repeated in 1 to 2 hrs if needed -individuals should be re-evaluated if antacids are used more than twice a week or regularly for over 2 weeks , frequent antacid users may need to be switched to H2RAs or PPIs . - Effervescent antacid containing NaHCO3 is contraindicated in heart diseases , renal failure and pregnant women due to their high sodium content (274 mg Na /gram ) which might increase the fluid overload -Some products in Egypt contain up to 767 mg of sodium . -Upper limit is 2300 mg of sodium per day for general population ,1500 mg for HTN, age 51+ , chronic kidney disease ( American Dietary guideline 2010) -Some of the Mg and Al may be absorbed and then excreted renally thus accumulation may occur in patients with renal insufficiency. -Mg containing antacids should not be used in patients with CrCl of less than 30 ml / min. -High intake of calcium along with an alkalinizing agent (ex: NaHCO3) may cause milk-alkali syndrome 2- H2-Receptor Antagoints (H2RAs) -Superior in efficacy when compared to antacids -Maybe used at the onset of symptoms or 30 mins to 1 hr prior to an event in which heart burn is anticipated ( meal or exercise) -The four compounds are virtually interchangeable -Ranitidine is now available in an OTC formulation at standard dose in the US -If used more than 14 days referral is recommended -Some patients will develop tolerance to H2RAs after 30 days of use -Dose : 1 -2 tablets per day H2RA + Antacid -offer fast onset and long duration -products in Egypt include :
(Famotidine 10mg + Ca2CO3 800mg + MgOH2 165mg)
(Famotidine 10mg + Al2OH3 250mg + MgOH2 250mg ) 3- Proton Pump Inhibitors (PPIs) -Not intended for immediate relief or occasional episodes of heart burn -if heart burn continues while on OTC PPIs for more than 2 weeks or recurs within 4 months referral is recommended -Meta-analyses fail to show significant difference in efficacy for symptom relief between PPIs (ACG guideline 2013) H2RAs & PPIs OTC dosage 4-Prokinetics -Metoclopramide , Domperidone , Cisapride , Mosapride -Works by : *Increase LESP *Enhance esophageal peristalsis *Enhance gastric emptying -Are not recommended as monotherapy for patients with GERD -Cisapride were taken off the US market several years ago due to increased cardiovascular risks -Mosapride when combined with omeprazole has been shown to improve reflux symptoms and gastric emptying -Usage of metoclopramide has been limited by CNS side effects including tardive dyskinesia in <1 % of patients Omeprazole-controlled randomized study 5-Baclofen : -Has been shown to offer symptomatic relief for patients with GERD -Decrease the number of transient LES relaxations and increase LES tone -Not considered to be first-line therapy -There is no long-term data published regarding efficacy of baclofen in GERD -Not FDA approved for the treatment of GERD Pregnancy & GERD -New onset GERD symptoms are common during pregnancy due mainly to the mechanical pressure placed on the stomach and intestinal tract as the uterus enlarges -Therapy for GERD during pregnancy usually takes a step-wise approach, starting with lifestyle modifications often combined with a trial of calcium containing antacids (ex: CaCO3) Case : 30 yrs old female complain of reccurring substernal moderate burning sensation after eating heavy meals , it occurs once a week and is associated with feeling of fullness and occasional acid regurgitation , symptoms typically last 2 – 4 hours after eating , the patient also takes ( ethinyl estradiol +  drospirenone) for contraception and Calcium citrate 630 mg with vitamin D 400 IU twice daily . H2 blocker before the heavy meal
ex : famotidine 20 mg 30 mins before the heavy meal *H2RAs are more preferred than antacids incase of moderate heart burn *Does not interact with her drugs *Advice the patient to avoid food that worsen her heart burn Peptic ulcer disease Guidelines used
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