30 Questions
What are some symptoms of GERD?
Belching and bloating
How is GERD commonly classified?
Symptom-based or tissue injury-based
What is a common risk factor for GERD?
Gender
What contributes to reflux in GERD?
Incompetent anti-reflux barrier
How is GERD diagnosed?
By obtaining a clinical history and considering various tests
What is the aim of GERD treatment?
To alleviate symptoms and prevent complications
What is an alternative to surgery being evaluated for GERD?
Endoscopic therapies
What is the primary pathophysiologic mechanism associated with Gastroesophageal Reflux Disease (GERD)?
Decreased intra-abdominal pressure
Which of the following is considered an extraesophageal GERD syndrome?
Chronic cough
What are the alarm symptoms that mandate further diagnostic evaluation in GERD?
Dysphagia and odynophagia
Which of the following medications can worsen the symptoms of GERD?
Calcium channel blockers
What is a common risk factor that can predispose a patient to GERD?
Elevated body mass index (BMI)
Which diagnostic test is appropriate based on the patient’s clinical presentation for GERD?
Upper endoscopy (esophagogastroduodenoscopy)
What are the benefits of proton pump inhibitors over H2-receptor antagonists in the treatment of moderate-to-severe GERD?
Fewer adverse effects
Which type of medication provides the greatest symptom relief and the highest healing rates for patients with erosive disease, moderate-to-severe symptoms, or complications?
Proton Pump Inhibitors (PPIs)
What is the mechanism of action of Proton Pump Inhibitors (PPIs) in gastric parietal cells?
Inhibiting H+/K+-adenosine triphosphate
What should be done with PPIs in patients with uncomplicated GERD after an empirical trial of >8 weeks?
Discontinue or lower the dosage
What is the role of Metoclopramide in treating patients?
Increasing LES pressure and accelerating gastric emptying
Which of the following medications interacts with PPIs by decreasing absorption and strongly inhibiting an enzyme responsible for the conversion of clopidogrel from prodrug to active ingredient?
Ketoconazole
What type of medication has variable effectiveness in treating patients with mild to moderate GERD and often less than desired response?
Histamine2 Receptor Antagonists (H2RAs)
What are the common side effects associated with Proton Pump Inhibitors (PPIs)?
Headache and fatigue
Which medication is limited in usefulness for treating gastroesophageal reflux disease (GERD) due to its many CNS side effects?
Baclofen
What is recommended for patients with extraesophageal symptoms who do not have typical GERD symptoms?
Ambulatory esophageal reflux pH monitoring
What should be considered before prescribing acid suppression therapy to infants with gastroesophageal reflux disease (GERD)?
Resolution of the condition by about 12 months
What is indicated for patients who respond to a proton pump inhibitor (PPI) trial or have endoscopic evidence of reflux?
Maintenance therapy
What may have a role in refractory GERD, depending on patient specific factors?
Antireflux surgery
What should be performed before committing to lifetime proton pump inhibitor (PPI) use if discontinuation is not possible?
Ambulatory esophageal reflux pH/impedance monitoring
What is lacking data to support its combination with acid suppression therapy for treating gastroesophageal reflux disease (GERD)?
Omeprazole/Na bicarbonate immediate release product
What is recommended for patients with uncomplicated GERD who respond to short term proton pump inhibitor (PPI) therapy?
Discontinuation or dose de-escalation
What should be evaluated regularly in patients using proton pump inhibitors (PPIs) to ensure the lowest possible effective dose is being used?
PPI dosing
Study Notes
- Antacids provide symptomatic relief by increasing gastric pH, but documentation in placebo-controlled trials is lacking.
- Potential drug-drug interactions with antacids include tetracycline, iron, sulfonylureas, antibiotics, and H2RAs.
- Antacids are typically used on an as-needed basis, but OTC H2RAs and PPIs may also be used according to package directions.
- Patients with moderate but non-alarm symptoms may be prescribed medications for GERD if they fail patient-directed treatment.
- Proton Pump Inhibitors (PPIs) provide the greatest symptom relief and the highest healing rates, especially for patients with erosive disease, moderate-to-severe symptoms, or complications.
- PPIs work by inhibiting H+/K+-adenosine triphosphate in gastric parietal cells and maintaining extended time with gastric pH >4, which is correlated with the healing of erosive esophagitis.
- PPIs, such as dexlansoprazole, esomeprazole, lansoprazole, omeprazole, omeprazole and sodium bicarbonate, pantoprazole, and rabeprazole, are available in various forms.
- PPIs should be discontinued in patients with uncomplicated GERD or the dosage should be lowered after an empirical trial due to rebound acid hypersecretion when used for >8 weeks, making withdrawal difficult.
- Data is lacking on a proper tapering protocol and various approaches may be considered on a case-by-case basis.
- BID dosing in those not responding to a standard once daily course of therapy and swapping to an alternative PPI can provide similar efficacy.
- Common side effects include headache, diarrhea, nausea, and abdominal pain, and increasing concerns with PPI safety have been reported.
- PPIs interact with various medications and decreasing absorption of ketoconazole or itraconazole, and omeprazole strongly inhibits CYP2C19, which is the enzyme responsible for the conversion of clopidogrel from prodrug to active ingredient.
- Alternative options exist for pediatric patients and those unable to swallow tablets/capsules, including delayed-release capsules, granules, oral suspension packets, orally disintegrating tablets, capsule sprinkles, or IV formulations.
- Histamine2 Receptor Antagonists (H2RAs), such as cimetidine, famotidine, and nizatidine, have variable effectiveness in treating patients with mild to moderate GERD and often less than desired response.
- Disease severity, dosage regimen used, and duration of therapy all affect response, and agent selection should be patient-specific.
- Common adverse effects include headache, fatigue, dizziness, constipation/diarrhea, and cimetidine has many drug interactions and may inhibit the metabolism of warfarin, theophylline, phenytoin, nifedipine, propranolol, and others.
- Metoclopramide, a promotility agent, increases LES pressure in a dose-related manner by accelerating gastric emptying.
Test your knowledge about medications used for managing gastric pH levels and providing relief from gastric symptoms. Explore the use, potential drug interactions, and prescription guidelines for antacids, H2RAs, and PPIs.
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