Heartburn Management Quiz

Heartburn/GERD OTC Handbook Ch 13

• Self-treatment goals include complete symptom relief, reduced recurrence, and management of medication side effects.
• Dietary triggers to avoid include fatty foods, spicy foods, chocolate, caffeinated beverages, carbonated beverages, citrus, salt substitutes, tomatoes, garlic or onions, mint, and alcohol.

Exclusions for Self-Treatment

• Frequent heartburn for more than 3 months
• Heartburn while taking recommended dosages of nonprescription H2RA or PPI
• Heartburn that continues after 2 weeks of treatment
• Heartburn and dyspepsia that occur when taking a prescription H2RA or PPI
• Severe heartburn and dyspepsia
• Nocturnal heartburn
• Difficulty or pain on swallowing solid foods
• Vomiting blood or black material
• Chronic hoarseness, wheezing, coughing, or choking
• Unexplained weight loss
• Continuous nausea, vomiting, or diarrhea
• Chest pain accompanied by sweating, pain radiating to shoulder, arm, neck, or jaw, and shortness of breath.
• Children under 2 years (for antacids), 12 years (H2RAs), or 18 years (for PPIs)
• Adults >45 years with new-onset dyspepsia

Risk Factors

• Dietary factors
• Lifestyle factors
• Diseases
• Medications
• Other factors (Further detail in Table 13-1)

Nonpharmacologic Management Options

• Weight loss
• Elevate the head of the bed (wedge, not pillows)
• Smaller meals
• Avoid eating before bedtime (3 hours)
• Smoking cessation
• Avoid alcohol

NonRx Pharmacologic: Antacids

• Neutralize gastric acid
• Treat mild, infrequent GERD symptoms only, no healing
• Formulations: Na, Mg, Ca, Al
• Inexpensive
• Rapid acting (within 5 minutes)
• Short duration

NonRx Pharmacologic: Antacids - Key Points

• Liquid, quick dissolve = faster onset
• Food increases duration of action
• Combining with analgesics for overindulgence
• Possible binding with ions (tetracycline, azithromycin, fluoroquinolones)
• pH affects absorption (iteraconazole, ketoconazole, Fe)
• Separate by 2 hours
• Many brands
• Constant changing combination products
• Read bottle dosage limits

NonRx Pharmacologic: Sodium Antacids

• Sodium Bicarbonate
• Produces CO2
• Eliminates rapidly from the stomach
• Shortest duration of action
• Common product: Alka-Seltzer

NonRx Pharmacologic: Sodium Antacid Caution

• Fluid overload
• Decreased renal function
• HTN
• Combined with Calcium
• Hypercalcemia
• Alkalosis
• Irritability
• Headache
• Nausea/vomiting
• Weakness
• Malaise

NonRx Pharmacologic: Magnesium Antacids

• Magnesium Hydroxide
• Shorter duration of action compared to Ca and Al products, longer than Na products
• 15-30% absorbed
• Diarrhea
• Patients with decreased renal function (contraindicated in <30.
• Example Product: Milk of Magnesia

NonRx Pharmacologic: Calcium Antacids

• Calcium Carbonate
• Produces CO2
• Slower onset, longest lasting agent
• 10% absorbed

NonRx Pharmacologic: Calcium Antacids Concerns/Safety

• Constipation
• Stimulates acid secretion
• Decreased renal function (calculi risk)
• Beware of other sources of calcium consumption
• Max 2500 mg/day
• Example products: Tums, Maalox chewable antacids

NonRx Pharmacologic: Aluminum Antacids

• Aluminum Hydroxide
• Slower onset/longer duration than Mg
• 17-30% absorbed
• Constipation - dose related
• Binds to phosphate
• Decreased renal function
• Example Product: AlternaGEL liquid

NonRx Pharmacologic: Alginic Acid

• Physical barrier
• Not FDA approved
• Listed as inactive ingredients
• Mixed data on efficacy
• Example Products: Mylanta Maximum Strength Liquid, Gaviscon

H2RAs (Histamine2 Receptor Antagonists)

• Two options: Cimetidine (Tagamet), Famotidine (Pepcid)
• Dosing: Low (nonprescription), Standard (non-prescription and prescription), High (prescription only) doses

H2RAs (Histamine2 Receptor Antagonists) - Key Points

• MOA: Inhibits histamine
• Decreases gastric acid secretion
• Prandial, fasting, and nocturnal
• Moderate onset (30-45 minutes)
• Moderate duration of action (4-12 hrs)
• Tolerance
• 60% symptom improvement
• 50% heal
• Side effects: headache, diarrhea, constipation, dizziness, drowsiness, thrombocytopenia (rare)

H2RAs (Histamine2 Receptor Antagonists) - Cimetidine

• Shortest acting
• Weak antiandrogen
• CYP isoenzyme action: 3A4, 2D6, 1A2, 2C9
• Inhibits renal secretion of drugs
• Lots of interactions
• Common brand name: Tagamet HB

H2RAs (Histamine2 Receptor Antagonists) - Famotidine

• Not hepatically metabolized
• Increases stomach pH – some minor drug interactions
• Common brands: Pepcid AC, Zantac 360°
• Safest of the two H2RA options!

PPIs (Proton Pump Inhibitors)

• Prilosec (omeprazole)
• Prevacid (lansoprazole)
• Nexium (esomeprazole)
• Zegerid (omeprazole and sodium bicarbonate)

PPIs (Proton Pump Inhibitors) - Key Points

• Inhibit hydrogen potassium ATPase
• Directly stops proton (acid) secretion
• Irreversible binding
• Slow onset (1-3 hours)
• Long duration of action (12-24 hours)
• Increased effectiveness with continued use (Max result 1-4 days)
• Moderate-severe GERD w/wo complications
• Take 30 minutes before meal – only active pumps
• 83% symptom relief
• 78% healing
• Acid labile: Delayed release
• Infants/children
• Can be compounded into suspensions

PPIs (Proton Pump Inhibitors) - Side Effects/Safety

• Diarrhea
• Constipation
• Headache
• Pneumonia
• C. Diff
• Increased risk of hip fractures
• Interaction with clopidogrel (?): PK/PGx considerations

Zegerid

• Omeprazole 20 mg
• Delayed release component
• NaHCO3 110 mg
• Immediate release component
• Great for nocturnal symptoms

NonRx Meds: Duration of Therapy

• For H2RAs and PPIs: up to 2 weeks
• If no response after the first week, seek medical attention
• For PPIs: 14 days every 4 months for OTC formulations

Insomnia OTC Handbook Ch 46

• Objectives include defining insomnia, characterizing sleep stages, suggesting sleep hygiene, counseling alcohol's impact, identifying insomnia type, comparing treatments, describing treatment strategies, clarifying when a patient is a candidate for self-care vs. physician referral.
• Insomnia is characterized by difficulty falling asleep, waking up too early, and not being able to get back to sleep, and not feeling refreshed after waking up.
• Insomnia is a common self-care complaint. A 2015 survey found 32% of respondents had sleep problems during the previous week; 20% used medication to treat insomnia of which 60% used OTC medications.
• Sleep stages and approximate times include:

Stage 1: 5–15 minutes; very light sleep; feeling of falling; non-rapid eye movement (NREM) sleep Stage 2: 5–15 minutes; light sleep; body temperature drops; heart rate slows; NREM sleep Stages 3 & 4: 5–15minutes each; slow-wave/delta sleep; stage 4 is deeper; body repairs itself; NREM sleep Stage 5: 10 minutes in first cycle, up to 1 hour in subsequent cycles; dreaming; brain activity similar to during waking; rapid eye movement (REM) sleep; sleep cycle restarts after REM

• Sleep cycle progresses through these stages repeatedly throughout the night. The first cycle takes 70-90 minutes to reach REM; the first REM stage lasts 5-7 minutes. The cycle repeats approximately every 70–120 minutes each cycle having less time in deep sleep and more time in REM. In older adults, total sleep duration is shorter, deep sleep is reduced, and the number of nocturnal awakenings is increased.
• Types of insomnia include transient (less than 1 week), short-term (1–3 weeks), chronic (3 weeks to years, often secondary), primary (sleep difficulty for at least 1 month impacting psychosocial functioning), and secondary (sleep difficulty due to another sleep disorder, medical disorder, psychiatric disorder, or medication).
• Substances that cause insomnia include allergies, anxiety, arthritis, asthma, BPH, chronic pain, depression, diabetes, GERD, menopause, sleep apnea, pregnancy, restless leg syndrome, Alcohol, Antidepressants, Amphetamines, Antihypertensives, beta-adrenergic agonists (albuterol), Caffeine, Corticosteroids, decongestants, diuretics at bedtime, nicotine, and thyroid preparations.
• Presentation of insomnia includes difficulty falling asleep, frequent awakenings, inability to fall back to sleep, and poor sleep quality. In those who are sleep-deprived, symptoms include fatigue, drowsiness, anxiety, depression, irritability, decreased concentration, and memory impairment..
• Treatment goals include improving symptoms, improving quality of life, and improving functioning, and initially trying to normalize the sleep cycle with sleep hygiene. Nonprescription and prescription sleep aids may be considered and Cognitive behavioral therapy (CBT) for insomnia can be very helpful.
• Exclusions to self-care include: those under 12, over 65, pregnant, those with frequent nocturnal awakenings, early morning awakenings, chronic insomnia, secondary insomnia, or significant sleep disturbances.
• Sleep hygiene tips include using the bed only for sleep or intimacy (including weekdays and weekends), establishing a regular sleep pattern, making the room comfortable for sleep, and relaxing before bed. It is also important to avoid electronics, eating meals close to bedtime, and engaging in exercise too close to bedtime. Caffeine, alcohol, and nicotine should be avoided four to six hours before bedtime. If unable to fall asleep, a person should get out of bed to engage in a relaxing activity until they feel tired.
• Pharmacologic Therapy includes Diphenhydramine which is the only one supported with "clear evidence." Dosing is 50mg at bedtime. Other medications, like Doxylamine, are used but are not as safe.
• Special populations include pregnancy and those who are lactating, elderly, and children. Considerations must be made based on age, pregnancy, and medications.
• Potential natural sleep aids include melatonin, valerian, kava kava, 5-HTP, passion flower, chamomile, hops, lavender, GABA.
• Melatonin is a hormone produced by the pineal gland, from tryptophan and stimulated by darkness, suppressed by light; plays a role in the circadian rhythm. A typical dose is 1-10mg at bedtime.
• Chamomile extract is useful but limited; it is an active ingredient that antagonizes GABA receptors.
• General counseling points include always suggesting sleep hygiene first, using only one medication at a time, referring if no improvement in 10 days, avoiding topical diphenhydramine in those under 12 or over 65, and avoiding alcohol with sleep medications.

Test your knowledge on self-treatment strategies for heartburn. This quiz covers dietary triggers, nonpharmacologic options, and the role of antacids in managing symptoms. Explore effective techniques to help alleviate heartburn and improve your dietary habits.