By Momin Inierat10720288

Dr.Ikhlas Jarrar

Lifestyle modifications modificationsOver-the-counter Over-the-counter medicationsmedications

– Head of bed elevation Antacids

– Avoidance of tight-fitting clothesH2 Receptor Antagonists (H2RAs)

– Weight loss Proton Pump Inhibitor (PPI)

– Restriction of alcohol

– Elimination of smoking Prescription Prescription medicationsmedications

– Dietary therapy Prokinetics

– Refraining from lying down after meals H2RAs

– Avoidance of evening snacks before bedtime

PPIs

SurgerySurgery

GERD Treatment OptionsGERD Treatment Options

Definition: retrograde movement of gastric contents into the esophagus. patients with GERD

may experience esophageal t issue damage (refluxesophagitis) and/or symptoms of heartburn. Epidemiology: 30-50% of Poulation1.Age.2.Gender.3.Pregnancy.4. Obesity.

Burning,, pressure or pain *GERD Pain Vs MI*. Bitter or acid taste in the mouth. Heartburn worsen after meal. Heartburn is not linked to exercise or

improve with rest. Dysphagia (difficulty swallowing). Odynophagiia (painful swallowing) Suggests

Severe Mucosal damage of esophagus.

Bleeding from esophageal ulcers.

pulmonary complications.

Patients who describe difficulty swallowing (Dysphagia) may have an esophageal stricture, cancer , or a motility disorder .

a. Drugs that reduce LES tone include calcium channel antagonists, nitrates, anti cholinergic agents, TCA, Anti-H, and oral contraceptives and estrogen.

b. Foods that reduce LES tone include chocolate, fatty foods, onions, peppermint,

and garl ic.c. Smoking (nicotine) reduces LES tone.

Other egs in Table 3.

Pharm. Should Ask About:a. Duration and frequency of symptoms.b. Severity of the pain and symptoms.c. Timing of the symptoms (especially in relation

to meals and at bedtime).d. Presence of other symptoms (nausea,

vomiting, bloody stools, weight loss).e. Use of alcohol or tobacco.f . Amount of high-fat foods, caffeine-containing

products, chocolate, and tomato based foods consumed

g. Medications used currently, including nonprescription medications.

h. Medications used to relieve heartburn and their effectiveness.

Patients with the following symptoms or conditions should be referred to a physician for evaluation rather than treated with nonprescription agents:

a. Severe abdominal or back painb. Unexplained weight lossc. Chest pain that is indistinguishable from ischemic paind. Difficulty or pain on swallowinge. Presence or history of vomiting bloodf . Black tarry bowel movements ( if not taking iron or bismuth

subsalicylate)g. Children < 12 years of ageh. Possibility of being pregnanti. Symptoms not responding to antacids or nonprescription H2RAs

within 2 weeks or recurring soon after stopping

Non pharmacologic Treatment:a. Elevate the head of the bed 6-10 inches with blocks.b. Eat evening meals at least 3-5 hr before going to bed to

allow adequate time for gastric emptying.c. Avoid foods that reduce LES tone.d. Avoid foods that irritate the esophagus such as tomato-

based products, coffee, citrus juices, and carbonated beverages (with or without caffeine) .

e. Reduce the size of meals.f . Avoid lying down for at least 2 hr after meals.g. Stop use of tobacco products.h. Limit alcohol intake.i . Limit caffeine-containing beverages.j . Lose weight if appropriate.

Pharmacologic: Antacids *generally relieve heartburn within 5-15 min

of administration. Antacid suspensions generally dissolve more easily in gastric acid and thereby work quicker.

*MOA: Weak Bases that Neutrelizes Gastric Acid.

*Because of their short duration, patients may need to take 4-5 doses throughout the day for adequate symptom relief. Antacids will not provide sustained neutralization of acid throughout the night .

should be used for only short-term relief of symptoms.

Contra indications: patients with edema, congestive heart failure, renal failure, cirrhosis, and patients on low-salt diets.

I t is the only systemic antacid available and can thus alter systemic pH.

is the most potent antacid ingredient but may cause constipation or ,less likely, diarrhea.

It is a good source of elemental calcium.

Use Of Ca-Containing Anti Acid in Preg. Can be used safely in pregnancy. But if high

levels of calcium in late pregnancy, this will increase risk of contractions & Pre term Birth.

of ten causes constipation. should be avoided in patients with

hemorrhoids or constipation, which is common in the elderly.

Aluminum hydroxide has the lowest neutralizing capacity of al l the antacids.

Aluminum accumulation can be a problem in patients with chronic renal insufficiency.

rarely is used alone for heartburn because it frequently causes diarrhea.

I f used in renal failure patients, hypermagnesemia can occur rapidly.

provide the highest ANC per volume of antacid and are used most frequently.

The predominant adverse effect of these combinations is diarrhea.

Malox Plus® Chew. Tab. Malox Plus® Susp.

Patients with renal failure: should avoid the use of all antacids.

Potassium and magnesium content of antacids should be considered for patients with cardiac disease.

Patients should not take > 500-600 mEq ANC of antacid per day.

Tablets must be chewed thoroughly to achieve optimal effect .

Palatability with antacid liquids may be increased with refrigeration (do not freeze) .

Antacids can interfere with the absorption of many drugs. In general , antacids should be spaced at least 2 hr apart from the administration of interacting drugs. This is of ten quite difficult to accomplish.

Important clinical interactions with antacids may occur with the following drugs:

1)Tetracycline Antibiotics 2)Quinolone Antibiotics 3)Iron Suplement 4)Digoxin

5)Azole Antifungals (Requires Acidic medium for absorp.)

MOA: works by reacting with sodium bicarbonate and saliva to form a viscous solution of sodium alginate. This viscous solution floats on the surface of gastric contents so that , when reflux occurs, sodium alginate rather than acid is refluxed, and irritation is minimized.

(a) Alginic-acid tablets must be chewed to be effective and should be followed by a full glass of water so that the viscous foam can float on it in the stomach.

(b) Alginic-acid products work best when patients are in the upright position. Thus these products should not be taken at bedtime or just before lying down

These medications inhibit gastric acid secretion by competitively blocking H2-receptors on the parietal cell.

By decreasing gastric acid secretion, the refluxed material is less damaging to the esophagus.

The onset of symptom relief with H2RAs is

1-2 hr, which is considerably longer than anti acids; however, the duration of action can last up to 10 hr.

All H2RAs are contraindicated in children < 12 years of age.

Nonprescription H2RAs can be used for relief or prevention of heartburn.

Patients with moderate to severe symptoms and/or esophageal mucosal lesions require higher doses of H2RAs than are available over the counter . Unlike patients with peptic ulcer disease, patients with GERD respond best to multiple daily doses of H2RAs rather than to single bedtime doses.

No Longer Used.

May impair the hepatic metabolism and

thus increase serum concentrations and the pharmacological effects of the following drugs:

Warfarin Phenytoin Theophylline

Unlike cimetidine, famotidine rarely impairs hepatic metabolism of other drugs.

Dose: 10-20 mg as needed for symptoms, up to twice daily; maximum dose 40 mg/day. Patients who anticipate heartburn or indigestion may take 10-20 mg (1 tablet ) 1 hr before eating; maximum of 2 tablets within a 24-hr period. Famotidine 10 mg suppresses acid secretion for 8-10 hr

Famot idine, calcium carbonate, magnesium hydroxide (Acidex Complete, Famodine Complete)® .

A chewable combination of an H2RA and an antacid

Dose: 75-150 mg as needed for symptoms, up to twice daily; maximum 150 mg/day

Ranitidine inhibits hepatic metabolism 5-10 times less than cimetidine; therefore, the potential for drug interact ions is very small.

it’s the Best Studied Agent to be used in pregnency rather than Famotidine.

Dose: 75 mg as needed for symptoms, up to twice daily.

Nizatidine rarely impairs hepatic metabolism of other drugs

These agents are extremely well tolerated.

The most common adverse effects reported with nonprescription doses are headache, diarrhea, dizziness, and nausea.

Patients with moderate to severe GERD may benefit from the addition of these medications, which stimulate esophageal motility and increase LES tone.

Prokinetic agents are available only by prescription.

Adverse effects, such as sedation, depression, and extra pyramidal effects, limit the usefulness of this agent for many patients, Galactorhea.

Domperidone (Motilium)® is Similar.

Withdrawn From Markets Due to Arhythmogenic Action.

Causes Fetal Ventricular Arrhythmia.

These prescription-only agents (except omeprazole) provide complete acid suppression by inhibiting the H+/K+ATPase pump on the surface of the parietal cell.

The duration of acid suppression with these agents is about 3 days.

Proton pump inhibitors are the most potent and effective agents available for relieving severe GERD symptoms and healing esophageal lesions.

In June 2003, the FDA switched omeprazole to OTC status for the prevention of symptoms of frequent (occurring 2 or more days per week) heartburn.

These OTC drugs should be used for no more than 14 days every 4 months, unless directed by a physician.

This drug may inhibit hepatic metabolism and thus increase serum concentration /pharmacologic effects of the following drugs: phenytoin, warfarin, and diazepam.

Adverse effects. Although rare, these may include headache, diarrhea, constipation, or dizziness.

Lanzoprazole: No Sig. D/I.

Pantoprazole: The Only Agent Available For PO & IV Administration.

Rapeprazole

Esomeprazole

Pediatrics:Gastroesophageal reflux occurs commonly in

infants and children. Signs and symptoms in pediatric patients

include vomiting, chest pain, irritability, feeding refusal , belching, and apnea.

Serious complications (e.g. , failure to thrive, esophageal strictures) can occur in infants and children.

Rx By:a. Antacids, with or without alginic acid, have

been widely used in infants and children, but their safety has not been clearly established.

b. H2RAs have been used safely in children under the supervision of healthcare providers.

However , the nonprescription H2RAs are not approved for use in children < 12 years of age unless directed by a physician.

Pregnancy: Heartburn occurs commonly during

pregnancy because of increased abdominal pressure owing to the expanding uterus, as well as reduced LES pressure resulting from high concentrat ions of estrogen and progesterone.

Nearly half of pregnant women experience GERD, especially during the third trimester .

Rx By: Antacids & Alginic Acid Are first Line.

H2RAs are Considered 2nd Line Agents.

Rantidine is the best studied one clinically.

No Significant Clinical Studies on PPI Because they Are the Newest Agents Yet.

Antacids & H2RAs Are Safe In Elderly.

Dose Adjustment is needed according to the decline in Renal Functions or Interacting Drugs.

content Brand names

Esomeprazole Ezomax®, Nexium.®Famotidine Famodin®, Gastrex.®Omeprazole Omepradex®,Omepra®, Locid®, Pepticum®,

Marial

Rantidine Ratadine®, GI care®, randine.®Ca Carb. Tums®,Calcimore .®Ca & Mg Carb. Rennie®, Fresco.®Aluminium & Magnisium OH

Maalox®, Alumag®

Metaclopromide Pramin®, Emestop.®Domperidone Motilium.®