Heartburn and Dyspepsia Presentation - PDF

Heartburn, Dyspepsia and Gas Paris Dade, PharmD PGY2 Ambulatory Care Resident January 30, 2025 Slides courtesy of Getzabeth E. Bosques Gómez, MPH, PharmD  Objectives ○ Describe the pathophysiology of heartburn and dyspepsia ○ Recommend appropriate non-drug...

Heartburn, Dyspepsia and Gas Paris Dade, PharmD PGY2 Ambulatory Care Resident January 30, 2025 Slides courtesy of Getzabeth E. Bosques Gómez, MPH, PharmD  Objectives ○ Describe the pathophysiology of heartburn and dyspepsia ○ Recommend appropriate non-drug therapy, nonprescription medications for heartburn, dyspepsia and intestinal gas ○ Describe the main classes of drugs used to treat heartburn/ dyspepsia and intestinal gas ○ Assess appropriateness of all treatment options for heartburn, dyspepsia, and intestinal gas including onset, efficacy, drug interactions, adverse effects, precautions/contraindications, dosing/administration and cost  Medications to know ○ Sodium bicarbonate-based antacids ○ Proton Pump Inhibitors (PPI) ○ Omeprazole ○ Calcium carbonate-based antacids ○ Lansoprazole ○ Esomeprazole ○ Magnesium based antacids ○ Simethicone ○ Aluminum based antacids ○ Alpha-galactosidase ○ Bismuth subsalicylate ○ Lactase enzyme ○ Histamine H2 Receptor Antagonists ○ Famotidine ○ Cimetidine  Pathophysiology Very common GI complaint Rarely a cause of mortality *This slide is Patients with GERD have reduced LES courtesy pressure (muscle tone and gastric contents of Lavinia Whetsel T, Garofoli G. Chapter 13: Heartburn and Dyspepsia. Handbook of can backflow into the esophagus Salama Nonprescription Drugs, 20th Edition  Parietal Cell Pathophysio logy c c Has receptors for Histamine Acetylcholine Gastrin c Prostaglandin E2 (protective) Serves as the target for pharmacological inhibition of acid secretion Basal acid secretion peak time is Parietal cell located in the upper late in the day to about Whetsel T, Garofoli G. Heartburn and Dyspepsia. Handbook of Nonprescription Drugs, 20th gastrointestinal tract  Heartburn Clinical Presentation Within 1 hour after Burning sensation eating (large meal, or behind the breastbone Exacerbated by lying that may radiate with ingestion of down or bending over toward the neck, throat, offending foods or beverages) and, occasionally, the back Burping, hiccups, nausea, and vomiting Regurgitation Mild and episodic are less common symptoms Whetsel T, Garofoli G. Heartburn and Dyspepsia. Handbook of Nonprescription Drugs, 20th Edition  Dyspepsia Clinical Presentation ○ Postprandial fullness (perceived as the prolonged persistence of food in the stomach) ○ Discomfort in the upper abdomen ○ Characterized by epigastric pain, burning, early satiety, or combinations thereof Whetsel T, Garofoli G. Heartburn and Dyspepsia. Handbook of Nonprescription Drugs, 20th  Treatment of acid disorders Reduce the Neutralize secretion of existing acid acid Anticholinergics H2 Proton Pump antagonists Inhibitors Antacids Whetsel T, Garofoli G. Heartburn and Dyspepsia. Handbook of Nonprescription Drugs, 20th Edition  Risk Factors for heartburn and dyspepsia Dietary Lifestyle Diseases Alcohol Emotions Insulin resistance Caffeinated beverages Obesity Motility disorders Carbonated beverages Smoking (tobacco) PUD Chocolate Stress Scleroderma Citrus fruit or juices Supine body Sjogren's disease Coffee position Zollinger-Ellison Fatty foods Tight fitting clothing syndrome Garlic or onions Spicy foods Other Tomato/tomato juice Genetics Sugars Pregnancy Mint Whetsel T, Garofoli G. Heartburn and Dyspepsia. Handbook of Nonprescription Drugs, 20th Edition  Medications Risk Factors for Heartburn and Dyspepsia Alpha-adrenergic antagonists, CCB, nitrates, Quinidine Anticholinergic agents, TCAs Aspirin/other NSAIDs, narcotic analgesics, prostaglandins Barbiturates, benzodiazepines Beta2 adrenergic agonists, theophylline Bisphosphonates Chemotherapy Dopamine Doxycycline, tetracycline, zidovudine Estrogen, oral contraceptives, progesterone, Iron, potassium Whetsel T, Garofoli G. Heartburn and Dyspepsia. Handbook of Nonprescription Drugs, 20th Edition  Treatment Goals 1. Provide complete relief of symptoms 2. Reduce recurrence of symptoms 3. Prevent and manage unwanted effects of medications Whetsel T, Garofoli G. Heartburn and Dyspepsia. Handbook of Nonprescription Drugs, 20th Edition Is the Patient candidate for self- care? Frequency Onset How often Lasting 3 or more months- GERD may be suspected Alarming Timing symptoms Since when have you Patient experiencing any experienced the symptoms? “alarm symptoms” or atypical or extraesophageal symptoms?  Treatment Approach Verify for exclusion criteria for self treatment Non- Considerations: pharmacologic Interactions al Preference recommendati ons Symptom severity Safety Cost Pharmacologic Therapy Whetsel T, Garofoli G. Heartburn and Dyspepsia. Handbook of Nonprescription Drugs, 20th Edition  Exclusions for Self-treatment ○ Frequent heartburn > 3 months with no pharmacological or diet treatments ○ Heartburn and/or dyspepsia persists while taking H2RA or PPI at the recommended doses or after 2-week trial of these medications ○ Difficulty/pain on swallowing ○ Vomiting blood or black material ○ Continuous N, V & D ○ Chest pain accompanied by sweating, pain radiating down shoulder, neck or jaw and shortness of breath Whetsel T, Garofoli G. Heartburn and Dyspepsia. Handbook of Nonprescription Drugs, 20th Edition  Nonpharmacologic Therapy ○ Weight loss ○ Nocturnal symptoms ○ Avoid eating within 2–3 hours of bedtime and sleep on their left side ○ Elevating the head of the bed by placing 6- to 8-inch blocks underneath the legs at the head of the bed or placing a foam wedge ○ Smoking cessation ○ Mediterranean diet ○ High intake of vegetables, legumes, fruits, whole grains, fish, and olive oil; low intake of red or processed meat ○ Symptom diary ○ To help determine foods, beverages, and activities that correlate with symptom onset and severity ○ Prescription and nonprescription medications ○ should be evaluated for triggers for heartburn and dyspepsia Whetsel T, Garofoli G. Heartburn and Dyspepsia. Handbook of Nonprescription Drugs, 20th Edition  Knowledge Check What is heartburn pathophysiology based on the information discussed in class? 1. Reduced lower esophageal sphincter (LES) pressure 2. Happens spontaneously 3. Process of passing air/gas through GI tract 4. Increased intracranial pressure  Knowledge Check A 40 y/o patient presents to the pharmacy consultation window complaining of a burning sensation behind the breastbone that started within 1 hour after eating a spicy tacos. The patient reported lying down makes it worse. What medical problem do you think she has? 1. Motion sickness 2. Heartburn 3. Influenza 4. Dyspepsia  Knowledge Check Select all the premises that are exclusions to self-treatment presented in the heartburn and dyspepsia lecture. 1. A patient who is Al ○ Magnesium (hydroxide, carbonate, or trisilicate) ○ Aluminum (hydroxide or phosphate) ○ Inexpensive MOA Indication Onset/ Dose Administratio Duration n Neutralizing Temporary Onset: < 5 Varies; read Take within 1 existing acid in relief of mild minutes product label hour after a the stomach and infrequent Duration: 20-30 meal, may heartburn and mins; up to 3 repeat every 4- dyspepsia hrs 6 hours Take alone or Whetsel T, Garofoli G. Heartburn and Dyspepsia. Handbook of Nonprescription Drugs, 20th Edition with PPI or Dissolve 2 tablets in 4 ounces of water every 4 hours PRN (8 tablets) Can increase the risk of serious bleeding * This slide is courtesy of Lavina Salama  Sodium bicarbonate Potency ○ NaHCO3 + HCl NaCl + H2O + CO2 Na>Ca>Mg>Al ○ Most potent antacid ○ Caution ○ In renally impaired patients can accumulate could cause metabolic alkalosis ○ Watch sodium overload ○ Patients with hypertension, edema, congestive heart failure, cirrhosis and in those on low salt diets ○ Milk-alkali syndrome: high intake of calcium and sodium bicarbonate ○ Side effects ○ Belching, flatulence, fluid overload in heart failure, renal failure, cirrhosis (liver problems), pregnancy (caution), sodium-restricted diets Whetsel T, Garofoli G. Heartburn and Dyspepsia. Handbook of Nonprescription Drugs, 20th  Calcium carbonate Potency ○ CaCO3 + 2HCL CaCl2 + H2O+ CO2 Na>Ca>Mg>Al ○ Most famous for TUMS ○ Dissolves more slowly in the stomach than sodium bicarbonate ○ Produces a potent and more prolonged neutralization of gastric acid ○ Caution ○ Hypercalcemia in patients with renal impairment ○ Side effect ○ Constipation, belching and flatulence ○ Major interaction: Phenytoin (Dilantin) PO ○ Chelation and loss of antileptic effect Whetsel T, Garofoli G. Heartburn and Dyspepsia. Handbook of Nonprescription Drugs, 20th Edition  Magnesium (hydroxide, carbonate, ○ Mg (OH) +2HCLMgor (Cl) trisilicate) + 2H O 2 Potency 2 2 ○ Of the magnesium salts, magnesium hydroxide is used most often Na>Ca>Mg>Al ○ Potent, short acting neutralizing action ○ Caution ○ Renal disease, which may result in systemic accumulation of magnesium Should not be used in patients with a CrCL < 30 mL/minute Magnesium toxicity sx: hypotension, electrocardiographic changes & bradyarrhythmia's ○ Side effect ○ Dose-related diarrhea *Dose varies if utilized Occurrence of diarrhea may be reduced by combining magnesium- as an antacid or laxative containing antacids with aluminum hydroxide Whetsel T, Garofoli G. Heartburn and Dyspepsia. Handbook of Nonprescription Drugs, 20th Edition  Aluminum Potency Na>Ca>Mg>Al ○ Al (OH)3 + 3HClAL (Cl) 3 + 3 H2O ○ Low neutralizing capacity ○ Binds dietary phosphate in the GI tract, increasing phosphate excretion in the feces ○ Caution ○ Prolonged may lead to hypophosphatemia ○ Patients with renal failure may lead to aluminum toxicity ○ Side effect ○ Dose-related constipation Whetsel T, Garofoli G. Heartburn and Dyspepsia. Handbook of Nonprescription Drugs, 20th Edition  Other Products and Additional Ingredients Consider some antacids contain sugar, enough to alter Sugars glucose in patients with labile DM Contain in most antacids, consult with PCP when > 5mEq Sodium (115 mg) sodium in the total daily dose Creates a raft that acts as a physical barrier, protecting esophageal tissues from gastric acid. Alginic acid May be used in combination with PPIs to better control GERD symptoms Product: Gaviscon: alginic acid plus antacid Whetsel T, Garofoli G. Heartburn and Dyspepsia. Handbook of Nonprescription Drugs, 20th Edition  Antacids Drug Interactions Antacids can bind (chelate) or absorb certain drugs when given at the same time Many more interactions! Decrease concentration of Tetracycline Levothyroxine Fluoroquinolones Separate by 2 hours Separate by at least 4 hours before or after before or 6 hours after Whetsel T, Garofoli G. Heartburn and Dyspepsia. Handbook of Nonprescription Drugs, 20th Edition  Bismuth Subsalicylate ○ No measurable acid neutralizing capacity ○ Has a coating action on the stomach mucosa ○ Indicated for heartburn, upset stomach, indigestion, nausea, and diarrhea ○ Also, reliefs upset stomach associated with belching and for gas associated with overindulgence in food and drink ○ Warning: it is a salicylate (related to aspirin) ○ Patients on anticoagulants should be warned not to take Pepto- Bismol ○ Bismuth compounds are converted by colonic bacteria into bismuth sulfide and cause blackening of the tongue and stools ○ Avoid in children: Risk of Reyes Syndrome Whetsel T, Garofoli G. Heartburn and Dyspepsia. Handbook of Nonprescription Drugs, 20th Edition Pharmacologic Therapy Histamine Type-2 Receptor Antagonists (H2RAs)  Histamine Type-2 Receptor MOA Antagonists Indication Onset /Duration (H2RAs) Administration Dose Inhibits acid -Mild to moderate Onset: 30-45 May be used at Reduced daily secretion by infrequent or episodic minutes the onset of dose is with blocking H2 heartburn symptoms or 30– impaired renal receptors on -Prevention of Duration: 4-10 60 minutes before function (CrCL gastric parietal heartburn associated hours an event in which 2 years), tachyphylaxis BEERS warning: risk of inducing or worsening delirium, risk of CNS effects in those with cognitive impairment Whetsel T, Garofoli G. Heartburn and Dyspepsia. Handbook of Nonprescription Drugs, 20th Edition 1 tablet daily or BID Max: (2 tablets) OTC and Rx ranitidine Many drug interactions products are still off the (moderate inhibitor of market due to concerns CYP450 2C19 and weak about the impurity NDMA inhibitor of other enzymes including 3A4) (N-nitrosodimethylamine) Brand name Zantac has been recycled and is now 1 tablet daily Max: (2 used as part of the brand tablets) Chew and swallow 1 tab name for the generic Max:2 tabs drug FAMOTIDINE  Drug Interactions H2RAs Also applies to Medications Iron products PPIs + that need Acid Azole's antifungals (e.g. ketoconazole, antacids to be itraconazole) Absorbed Antiretrovirals (rilpivirine, atazanavir) Phenytoin Cimetidine and Warfarin CYP450 Theophylline Inhibition Clopidogrel Many more … Whetsel T, Garofoli G. Heartburn and Dyspepsia. Handbook of Nonprescription Drugs, 20th Edition Pharmacologic Therapy Proton Pump Inhibitors (PPI)  Proton Pump Inhibitors (PPI) MOA Indication Onset/Duration Administration Blocks acid Treatment of Onset: 2-3 hours 30-60 minutes secretion by binding frequent Duration: 12-24 BEFORE meal with to H+/K+ heartburn (≥2 hours glass of water exchanging days per week) or Full relief: 1-4 days ATPase in gastric when not responsive Do not crush or parietal cells to non-Rx H2RA, Age chew capsules or > 18 years old tablets Side effects/Safety considerations: Headache, abdominal pain, diarrhea, constipation, or flatulence (mild and infrequent) Rare cases of acute interstitial nephritis and subacute cutaneous lupus erythematosus Risk of infectious traveler’s diarrhea Risk of Clostridioides difficile infection Hypomagnesemia, vitamin B12 deficiency, reduced bone mineral density (high doses and or long term), community-acquired pneumonia, chronic kidney disease, and dementia Limit for self treatment is 14 days, and retreatment to every 4 months Whetsel T, Garofoli G. Heartburn and Dyspepsia. Handbook of Nonprescription Drugs, 20th  ESOMEPRAZOLE 1 tablet 30 minutes before morning meal OMEPRAZOL E 1 capsule 1 hour before morning meal 1 capsule with a glass of water 30 minutes before morning meal LANSOPRAZOLE 1 capsule with a glass of water 30 minutes before morning meal  PPI: drug-drug interactions CYP2C19 inhibition ↓ concentration of ↑ concentration of clopidogrel (antiplatelet citalopram, warfarin, drug metabolized thru digoxin, methotrexate CYPC19)-not clinically significant? Whetsel T, Garofoli G. Chapter 13: Heartburn and Dyspepsia. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care,  Special Populations Pregnancy Lifestyle modifications (eg, smaller meals) should be tried before drugs Preferred: Antacids (calcium- or magnesium-containing) H2RA may be used if no relief with antacids. Famotidine preferred PPIs should be reserved for severe symptoms Breastfeeding Aluminum-, calcium-, or magnesium-containing antacids are considered safe H2RA famotidine is less concentrated in breast milk-is preferred Children (>2 For mild, transient, and infrequent heartburn, acid indigestion, or y/o) sour stomach, children’s formulas of calcium carbonate- containing antacids H2RAs are labeled for patients 12 years of age and older Nonprescription PPIs are indicated for patients 18 years of age or older Whetsel T, Garofoli G. Chapter 13: Heartburn and Dyspepsia. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care,  Knowledge Check Which one of the following statements about antacids in pregnancy is true? 1. Proton pump inhibitors are first-line 2. Calcium- or magnesium-containing antacids are preferred 3. Eating smaller meals should be recommended before trying OTC medications 4. Both B and C are correct  Key Points ○ Dietary and lifestyle modifications are equally important at the patient education level ○ Self treatment limited to mild or moderate symptoms ○ Antacids provide temporary relief ○ H2RAs may be taken at the onset of symptoms or 30–60 minutes before an event that may cause symptoms. ○ PPIs are indicated for treatment of frequent heartburn (occurring ≥2 days a week) and should be used for a maximum of 14 consecutive days ○ Pregnant women may self-treat for mild and infrequent heartburn with calcium- and magnesium-containing antacids Supplementary slides  Clinically Important Drug-Drug Antiacid Medication Interactions Drug/ drug class DDI Potential Interaction Management Antacid Itraconazole, Increased gastric pH may Separate doses by at least ketoconazole, iron, decrease disintegration, 2 hours. atazanavir dissolution, or ionization of drug leading to decreased absorption. Amphetamines Absorption of amphetamines Avoid concurrent use or is increased, and excretion monitor response to decreased. therapy. Rosuvastatin Absorption of rosuvastatin is Separate doses by at decreased least 2 hours. Infrequent use of antacids is unlikely to cause clinically significant interaction. Enteric-coated Increased gastric pH may Separate doses by at medications cause premature breakdown least 2 hours. of enteric coating. Whetsel T, Garofoli G. Chapter 13: Heartburn and Dyspepsia. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care,  Clinically Important Drug-Drug Antiacid Medication Interactions Drug/ drug class DDI Potential Interaction Management Calcium carbonate, Levothyroxine Absorption of levothyroxine Separate doses by at magnesium is delayed or impaired. least 4 hours. hydroxide, Tetracyclines Absorption of antibiotic is Separate doses by at aluminum decreased. least 4 hours. hydroxide Fluoroquinolones Absorption of antibiotic is Take antibiotic 2 hours decreased. before or 6 hours after taking antacid. Magnesium Azithromycin Absorption of antibiotic is Separate doses by at hydroxide, decreased. least 2 hours. aluminum hydroxide Sodium bicarbonate Quinidine Increased urinary pH may Avoid concurrent use or decrease renal excretion of monitor response to quinidine. therapy. Salicylates Increased urinary pH may Avoid concurrent use or increase renal excretion of monitor for decreased salicylates response to salicylates. Whetsel T, Garofoli G. Chapter 13: Heartburn and Dyspepsia. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care,  Clinically Important Drug-Drug Interactions Antiacid Medication Interacting medication Potential Interaction Management H2RAs, PPIs Itraconazole, Increased gastric pH Avoid concurrent use ketoconazole, atazanavir, may decrease or monitor response to iron sulfate, calcium disintegration, therapy. carbonate dissolution, or ionization of drug, leading to decreased absorption. Cimetidine Phenytoin, warfarin, Cimetidine inhibits Avoid use of amiodarone, clopidogrel, CYP450 1A2, 2C19, cimetidine in patients nifedipine, theophylline, and to a lesser extent, taking medications tricyclic antidepressants, 2D6, 3A4. metabolized by these others CYP enzymes. Cimetidine, Citalopram Inhibition of CYP450 Citalopram dose esomeprazole, 2C19 increases should not exceed 20 lansoprazole, citalopram mg per day if used omeprazole concentrations and concomitantly. dose-dependent risk of QT prolongation. Whetsel T, Garofoli G. Chapter 13: Heartburn and Dyspepsia. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care,  Clinically Important Drug-Drug Antiacid Medication Interactions Interacting medication Potential Interaction Management PPIs Warfarin, tacrolimus PPI inhibition of Avoid concurrent use CYP2C19 may result or check with in increased prescriber. concentrations of target drugs. Digoxin PPIs may increase Check with digoxin absorption. prescriber before use. Methotrexate Concurrent use Avoid concurrent use increases risk of of high-dose toxicity of methotrexate. methotrexate. Clinically significant toxicity is unlikely with lower weekly doses. Whetsel T, Garofoli G. Chapter 13: Heartburn and Dyspepsia. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care,  Clinically Important Drug-Drug Interactions Antiacid Interacting Potential Management Medication medication Interaction Omeprazole, Clopidogrel Inhibition of variants Avoid concurrent use esomeprazole of CYP2C19 reduces or check with conversion of prescriber. Clinically clopidogrel to its significant interaction active form. is unlikely. Cilostazol, diazepam Inhibited metabolism Avoid concurrent use. may result in Lansoprazole may be increased a safer alternative. concentration of target drug. Whetsel T, Garofoli G. Chapter 13: Heartburn and Dyspepsia. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, Whetsel T, Garofoli G. Chapter 13: Heartburn and Dyspepsia. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 20th Edition  Study Guide Questions ○ What is the pathophysiology of heartburn and dyspepsia? ○ Mention nonpharmacologic interventions for heartburn ○ What is the MOA, onset, and duration of action of antacids? ○ Which is relatively the most potent antacid? ○ What antacid has a higher probability of causing diarrhea? ○ What antacid has a higher probability of causing constipation? ○ What is a general rule of thumb to counsel patients when antacids are taken with levothyroxine or fluoroquinolones ? ○ What antacids are the best choice in pregnancy? ○ What is the active ingredient in children’s Pepto? ○ What is Reyes syndrome? ○ What is the MOA, onset, duration of action, and safety precautions with H2RA? ○ At what time typically can we recommend taking H2RA? ○ What are the MOA, onset, duration of action, and safety precautions with PPI? ○ What is the indication for PPI? ○ At what time typically can we recommend taking PPI? Intestinal Gas  Background What is gas or flatulence? ○ Process of passing air/gas through GI tract What are some symptoms for intestinal gas? ○ Belching, bloating, flatulence, abdominal pain/discomfort ○ Could be accompanied by nausea, dyspepsia, or heartburn What are some causes for intestinal gas? ○ Swallowing air (gum, smoking) ○ Foods (carbonated drinks, veggies, dairy) ○ Bacteria breaking down food products ○ Genetic/disease state such as carbohydrate malabsorption ○ Alterations in intestinal flora from antibiotics, sickness ○ Medical conditions (celiac, gastroparesis, IBS) ○ Drugs that affect GI motility, intestinal flora, or affect glucose metabolism Jackowsk R, Poole TM. Intestinal Gas. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 20th  Treatment Goals Reduce frequency, intensity, duration of intestinal gas symptoms Reduce impact symptoms on patient’s lifestyle Jackowsk R, Poole TM. Intestinal Gas. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 20th  Treatment Approach ○ Assess patient’s history and severity of symptoms, diet, eating habits, medication use, relevant medical conditions ○ Food/diet associated? ○ Lactose-containing foods? ○ Oligosaccharide containing foods? Jackowsk R, Poole TM. Intestinal Gas. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 20th Exclusions for Self-Treatment Persistent gas (more than several days or several times/month) Severe debilitating symptoms Sudden change in location of abdominal pain, significant increase in frequency or severity of symptoms, Onset of symptoms in individuals > 40 years of age (never had gas ever before) Symptoms accompanied by significant abdominal discomfort or sudden change in bowel function Presence of accompanying symptoms such as severe or persistent diarrhea or constipation, GI bleeding, fatigue, unintentional weight loss, or frequent nocturnal symptoms * This slide is courtesy of Lavina Salama Jackowsk R, Poole TM. Intestinal Gas. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 20th Foods Associated With Major Gas Production Vegetables: onions, celery, carrots, Brussel sprouts, cucumbers, cabbage, cauliflower, radishes, leeks, parsnips, peas, green salads, beans, potatoes Fruit: raisins, bananas, apricots, prunes, dried fruit Carbohydrates: whole grains, wheat germ, bran, brown rice Dairy: milk, ice cream, cheese Carbonated beverages Beans, eggs, fried/fatty foods * This slide is Artificial sweeteners courtesy of Lavina Jackowsk R, Poole TM. Intestinal Gas. Handbook of Nonprescription Drugs, 20th Edition. Salama Non-Pharmacological Management ○ Take the time to chew well ○ Avoid ‘washing down’ solids with a beverage, chewing gum, hard candy with artificial sweeteners ○ Smoking cessation ○ Check dentures for proper fit ○ Attempt to be aware of and avoid deep sighing ○ If increasing fiber, do so gradually ○ Avoid medications that cause symptoms (consult provider) ○ Avoid gas producing foods and beverages (e.g., sodas, beer) ○ Avoid foods with air whipped into them ( e.g., whipped cream, souffles, sponge cake, milkshakes) Jackowsk R, Poole TM. Intestinal Gas. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care, 20th  OTC Pharmacologic Options Antiflatulence medications ○ Simethicone ○ Activated charcoal Digestive enzymes ○ Lactase replacement ○ Alpha-galactosidase products Probiotic products ○ Bifidobacterium ○ Lactobacillus ○ Saccharomyces (a yeast) ○ Other species Lippincott Illustrated Reviews: Pharmacology 6th edition, R. Harvey Jackowsk R, Poole TM. Intestinal Gas. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care  Simethicone (Gas-X) MOA Indication Dose Side effects Notes Defoaming agent ↓ Relief of pressure, 40-125 mg after meals Minimal/ None Considered safe surface tension of bloating, fullness, and at bedtime PRN reported in pregnancy and gas bubbles discomfort of breastfeeding embedded in the intestinal gas >12 years (MAX 500 Considered safe mucus of the GI tract mg/24 hrs) and effective Used to treat intestinal gas Children ages 2-