Gastroesophageal Reflux Disease Essay, Research Paper

Gastroesophageal Reflux Disease

Robert Shuder

Longitudinal Care

Dr. Slater

3/26/01

Overview of GERD

10% of all Americans experience GERD

Low mortality rate approximately 1 death per 100,000 persons

Largely effects QOL: more than angina, menopause,untreated HTN, mild CHF

GERD is defined as:

Clinical or histological disorder resulting from gastric materials “refluxing” into the esophagus

This reflux causes a breakdown of the esophageal mucosa

Pathophysiology of GERD

Excessive reflux of gastric juices from the stomach to the esophagus resulting in a breakdown of the defensive mechanisms of the esophagus.

This breakdown leads to irritation and injury of the esophageal mucosa.

Pathophysiology of GERD

Causes of esophageal mucosa breakdown:

Transient/spontaneous LES relaxation

Transient increase in intra-abdominal pressure

Atonic LES

LES tone can be caused by certain foods, drugs, hormones, or other physiologic factors

Typical Presentation

Classic Symptoms: “Heartburn”

Hypersalivation, belching, and regurgitation especially after a large meal

Antacids are commonly used to treat this symptoms

Atypical Presentation

Chronic cough, hoarseness, pharyngitis, and angina like pain

Non-allergic asthmatic symptoms have been reported

Further work is usually needed

Complicated Presentation

Continual pain, dysphagia, bleeding, weight loss, choking and chest pain

Differentiate from MI or Angina Pain

Further work up is necessary

Diagnostic Testing for GERD

Endoscopy

24 hour pH monitoring

Barium esophagogram

Acid perfusion test (induce reflux)

Treatment Goals

Alleviate pain and discomfort associated with the symptoms of GERD

Decrease frequency and duration of reflux

Promote esophageal healing

Avoid complications

Prevent recurrence

Types of Treatment

Non-Pharmacologic

Often used as monotherapy in mild or intermittent heartburn from GERD

Pharmacologic

May be used in mild cases if uncontrolled from non-pharmacologic treatment alone

Always used for more severe cases

Accompanied by non-pharmacologic treatment

Non-Pharmacologic Therapy

1) Elevate head of bed (6-8 inches)

2) Avoid large meals and aggravating foods

3) Smoking cessation

4) Avoid tight-fitting clothing

5) Avoid Alcohol consumption

6) Evaluate current drug therapy

Pharmacological Therapy

Antacids

Tums, Mylanta, Rolaids

H2- Antagonists

Pepcid, Zantac, Tagament

Prokinetic Agents

Metoclopramide

Proton pump inhibitors

Prilosec, Prevacid

Stepwise Treatment

Treatment for Step 1 patients

Indicated for mild, intermittent reflux

Life-style modifications (Non- pharmacologic therapy)

+/- Pharmacologic therapy

Antacids or OTC H2-antagonists as needed

Stepwise Treatment

Treatment for Step 2a patients

Mild to moderate, typical symptoms not relieved by Step 1 treatment or Atypical symptoms

Life-style modifications

+ Pharmacologic threatment

Prescription H2 Antagonists, proton pump inhibitors or Prokinetic agents

Stepwise Treatment

Treatment for Step 2b patients

Moderate to severe symptoms or those with erosive disease

Life-style modifications

+ Pharmacologic treatment

Higher dosed H2 antagonists or Proton Pump Inhibitors

Stepwise Treatment

Treatment for Step 3 patients

Surgery

Reconstruction of lower esophageal sphincter

Indicated for patients with moderate to severe symptoms or those with erosive disease

90% effective

Indicated last line when drug therapy has failed

Not indicated for the elderly population

Pharmacoeconomic Considerations

Drug efficacy vs. Therapeutic Outcomes

Many interaction with some agents and less with others

Drug Efficacy vs. Direct Cost

Weigh the advantages & disadvantages of each

Patient Compliance

High cost can cause compliance issues

Therapeutic Outcomes

Measurements of Success

Ability to relieve symptoms

Healing of injured mucosa

Decreased risk of complications

Patient Education

Non-pharmacological treatment

What to expect form the medication?

Safety and Efficacy

Mechanism Of Action

H2 Receptor Antagonists

Competitive Equilibrium Antagonist at the H2 Receptor resulting in a block of acid secretion

Proton Pump Inhibitor

2 separate drug molecules bind covalently to the proton pump and inhibit its acid secreting ability

Mechanism Of Action

Sucralfate

Forms a gel which has high affinity for an ulcerated site and protects that site from the acidic envirionment of the stomach

Metoclopramide

Increases gastric motility to speed up digestive process which decreases reflux occurrence

Antacids

Weak bases which neutralize the stomach acid and decrease reflux

Antacids

Tablets

1)Maalox XS (Strongest)

2)Tums Ex

3)Mylanta

4) Rolaids (Weakest)

Liquids

1)Riopan Plus(Strongest)

2)Maalox Whip XS

3)Mylanta II

4)Gaviscon (Weakest)

Antacids

Used as P.R.N Treatment

Not recommended for chronic use

Ingridients

Sodium Bicarbonate

Calcium Carbonate

Aluminum Hydroxide

Magnesium Hydroxid

H2 Receptor Antagonists

Cimetidine (Tagmet)

Dose = 400-600mg BID or 800mg QHS

SE = Diarrhea, HA, Skin rash, dizziness

Many drug interactions due to cyp450 inhibition

Pregnancy category B

Dosage adjustments are needed for patients with renal and hepatic dysfunction

H2 Receptor Antagonist

Famotidine (Pepcid)

Dose = 40mg QHS

SE = HA, dizziness, diarrhea, constipation

Very few drug interactions have been reported

Pregnancy category B

No dose adjustment needed for patients with hepatic dysfunction

H2 Receptor Antagonist

Ranitidine (Zantac)

Dose = 150mg BID or 300mg QHS

SE = Fatigue, dizziness, HA, GI discomfort

Interactions with Procainamide, Diazepam, and Warfarin have been reported

Pregnancy category B

No dose adjustment is required for patients with hepatic dysfunction

Proton Pump Inhibitors

Omeprazole (Prilosec)

Dose = 20mg QD

SE = HA, dizziness, diarrhea, abdominal pain, nausea, vomiting

Omeprazole increases the concentrations of Benzodiazepines, phenytoin, and warfarin

Clarithromycin and Sucralfate will decrease Omperazole concentrations

Pregnancy category C

Dose adjustment required for patients with liver impairment but not for renal impairment

Proton Pump Inhibitors

Lansoprazole (Prevacid)

Dose = 30mg QD

SE = Same as with Omeprazole

Lansoprazole decreases theophyline concentrations

Sucralfate decreases Lansoprazole levels

Pregnancy category C

Dose adjustment for liver dysfunction patients but not for renal patients

Other Agents To Treat GERD

Sucralfate (Carafate)

Dose = 1 gram QID on an empty stomach

SE = constipation

Many drug interactions

Pregnancy category B

No dosage adjustments needed for kidney or liver impaired patients

Other Agents To Treat GERD

Metoclopramide (Reglan)

Dose = 10-15mg QID

SE = Restlessness, drowsiness, fatigue

Many drug interactions

Pregnancy Category B

Dosage adjustment are required for renally impaired patients

No adjustment needed in hepatic impairment

Monitoring Parameters

Decreases signs and symptoms of GERD

Monitor for appropriate OTC use

Hypersensitivity reactions ex. Rash

Side effects to the specific agent being used

Change in social habits

Decreased alcohol use and smoking