Gastroesophageal reflux disease GERD
- PowerPoint presentation on a primary care problem : GERD
- Present a fictional patient with the assigned medical condition to address all of the following:
- Describe the most commonly prescribed drugs for the assigned condition.
- Provide evidence by sharing clinical guidelines, research articles, or other scholarly materials to support your findings.
- Identify barriers to practice or issues related to the condition and the use of pharmacologic treatment, including potential issues related to cultural diversity and healthcare literacy.
- Describe the expected outcomes for medication management, including expectations for follow up care.
- A full reference list should be included in APA format on the final slide.
- Additionally, you will create five (5) multiple choice or true-false questions derived from powerpoint content. Include the questions on a slide in your presentation.
ScenarioA 54 year old Hispanic male patient arrived at the clinic. He reports intermittent chest pain with substernal burning that radiates to his mid-back. He describes this pain as stabbing. The patient states that the symptoms occur after he has eaten a large meal and in the middle of the night, which often wakes him from his sleep. He awakens with shortness of breath, coughing, and a bitter taste in his mouth. In the recent days, he has started to have nausea that is often worse in the morning or when he skips a meal. His complaints also include what he describes as “heartburn” up to 4 times daily. He keeps Tums with him at all times to help with the symptoms. His vitals are as follows: BP 132/860 lying, 122/70 standing; P 94; R 20; T 98.6F; Pulse Ox 94% on room air.
Esophagus. Gastroesophageal reflux disease GERD is a complex of symptoms of esophagitis, including burning pain in midepigastrium or behind lower sternum that radiates upward or “heartburn.” Occurs 30 to 60 minutes after eating; aggravated by lying down or bending over.
Gastric ulcer pain is dull, aching, gnawing epigastric pain, usually brought on by food and radiates to back or substernal area. Pain of perforated ulcer is burning epigastric pain of sudden onset that refers to one or both shoulders.
Gastroesophageal Reflux Disease in Older Adults: an Overview Description/Etiology Gastroesophageal reflux disease (GERD) is a motility disorder in which abnormal reflux of gastric contents into the esophagus causes mucosal damage, heartburn, and other clinical manifestations. The pathogenesis of GERD is multifactorial; factors that lead to GERD include abnormal lower esophageal sphincter (LES) pressure, altered esophageal mucosal resistance to gastric secretions, delayed esophageal clearance, and delayed gastric emptying. Older adults with GERD tend to have different signs and symptoms and are more likely to develop GERD-related complications than are younger patients. Older patients are less likely to experience the classic symptoms of GERD (e.g., heartburn, regurgitation) and are more likely to have atypical symptoms that include dysphagia, vomiting, chest pain, prolonged laryngitis, and/or chronic cough. Older adults with GERD are at high risk for complications, including hemorrhagic esophagitis, peptic strictures, and Barrett’s esophagus (for more information, see Quick Lesson About … Barrett’s Esophagus ). GERD can be diagnosed based on symptoms alone or by performing diagnostic tests such as upper gastrointestinal (GI) endoscopy (e.g., esophagogastroduodenoscopy) with biopsy, measuring and monitoring esophageal pH, upper GI series with barium swallow, and acid perfusion (Bernstein) test. The goals of treatment in older adults with GERD are the same as in younger patients with GERD, and include symptom resolution, healing of esophagitis, management of complications, and maintenance of remission. First-line therapy involves educating regarding the importance of making certain lifestyle changes (e.g., weight loss, dietary alterations); most patients require pharmacotherapy. An 8-week treatment course of a proton pump inhibitor (PPI) is recommended as first-line pharmacotherapy for GERD to heal erosive esophagitis and provide symptomatic relief. Histamine-2(H2)-receptor antagonists, prokinetic agents, and/or antacids can also be prescribed. In severe cases, surgery (e.g., laparoscopic Nissen fundoplication) can be needed. Facts and Figures GERD is usually diagnosed in persons who are over 40 years of age and is common in older adults. GERD affects 14–20% of adults in the United States. Epidemiological data regarding GERD in older adults are conflicting. There is some evidence that the prevalence of GERD is higher in older than in younger adults, but it is unclear whether the incidence of GERD increases with age or if reports of higher prevalence of GERD in older patients are explained by a steady accumulation of cases over time. It is also possible that GERD is underdiagnosed in older adults, for reasons including age-related decreases in nociception and visceral sensation. Risk Factors The effect of age as a risk factor for GERD is unclear, but certain risk factors for GERD are more common in older adults. Older adults tend to take more medications than younger adults; medications that can contribute to the development of GERD include calcium channel blockers, beta blockers, anticholinergics, benzodiazepines, theophylline, nitrates, barbiturates, narcotics, NSAIDs, bisphosphonates, and potassium supplements. Older adults are more likely to have hiatal hernia and/or disease conditions (e.g., diabetes mellitus, Parkinson disease, stroke, or dementia) that can affect esophageal and GI motility and/or tone. Signs and Symptoms/Clinical Presentation Older adults with GERD are less likely to have classic symptoms of GERD and are more likely to experience dysphagia, vomiting, chest pain, prolonged laryngitis, chronic cough, hoarseness, postprandial fullness, and belching. Assessment › Patient History • Assess risk factors, including medical history and medication use › Diagnostic Tests/Studies • Upper GI endoscopy (e.g., esophagogastroduodenoscopy) with biopsy is used to identify complications of GERD, including esophagitis, strictures, and Barrett’s esophagus • Esophageal pH monitoring will assess for the presence of reflux • Upper GI series or barium swallow will evaluate for anatomic abnormalities, including stricture and hiatal hernia • Bronchoscopy is performed if reflux into lungs is suspected • Esophageal manometry is performed preoperatively in patients who are scheduled to undergo surgical treatment for GERD • Radionuclide scintigraphy will measure gastric emptying Treatment Goals › Promote Symptom Resolution and Reduce Risk for Complications • Monitor vital signs, assess all physiologic systems (especially GI system), and review results of laboratory/other diagnostic studies; immediately report abnormalities and administer prescribed treatment • Administer prescribed medications, which can include –antacids to neutralize gastric acid –PPIs (e.g., omeprazole, lansoprazole) and H2 blockers (e.g., raNITIdine, cimetidine, famotidine) to inhibit acid secretion –prokinetic agents (e.g., metoclopramide) to improve esophagogastric motility –H2-receptor antagonists as maintenance therapy for patients without erosive disease • Monitor treatment efficacy and for adverse effects, including –mental status changes, which have been reported in older adults receiving cimetidine and ranitidine, particularly in older adults who have renal or hepatic dysfunction –muscle tremors, spasm, agitation, insomnia, drowsiness, confusion, and tardive dyskinesia in patients receiving long-term metoclopramide • Assess fall risk and follow facility protocols to maintain patient safety (e.g., airway, circulation, prevention of injury) • Request referral to a registered dietitian for patient evaluation and education regarding nutrition, consuming a healthy diet, and making dietary changes to promote symptomatic relief of GERD • Follow facility pre- and postsurgical protocols if patient becomes a surgical candidate (e.g., for laparoscopic Nissen fundoplication) –Reinforce pre- and postsurgical education, and verify completion of facility informed consent documents › Promote Emotional Well-Being and Educate Patient/Patient’s Family • Assess patient/family anxiety level and for knowledge deficits regarding GERD and its treatment; provide emotional support and educate about GERD pathophysiology, potential complications, treatment risks and benefits, and individualized prognosis • As appropriate, request referral to a social worker for identification of local resources for health education programs, support groups, in-home services, transportation, and assistive devices Food for Thought › Because of the increased risk for GERD-related complications, a more aggressive treatment approach might be needed when treating older adult patients, including higher doses of prescribed medications and earlier screening for complications compared with younger patients › Researchers in a randomized controlled trial including 1,235 patients diagnosed with GERD found that manual acupuncture or electroacupuncture treatment for GERD in combination with Western medicine (WM) versus WM alone, improved symptoms in patients with GERD. Patients also described that acupuncture improved their QOL (Zhu et al., 2017) › Alginates are alternative medications that can remove the post-prandialgastric acid pocket (i.e.,a pH < 4 in anarea of the proximal stomach between nonacid food and lower esophageal sphincter). Researchers in a systematic review and meta-analysis found that Alginate-based therapies decreased GERD symptoms compared with placebo or antacids, but were less effective than PPIs or H2receptor antagonists (Leiman et al., 2017) › The American College of Physicians recommends performing upper endoscopy for patients with GERD in the following cases (Shaheen et al., 2012): • Patients who have heartburn, dysphagia, bleeding, anemia, weight loss, and recurrent vomiting • Patients who have GERD-related symptoms that persist after a 4–8 week course of a PPI taken twice each day is completed • To evaluate for healing and for the presence of Barrett’s esophagus inpatients with erosive and severe esophagitis following 2 months of treatment with a PPI • For surveillance monitoring every 3–5 years for patients with Barrett’s esophagus who do not have dysplasia and more frequently for those with dysplasia. • Patients who have an esophageal stricture and persistent dysphagia Red Flags › Although PPIs are relatively safe and generally well tolerated, long-term PPI use has been associated with increased risk of • diarrhea associated with Clostridium difficile infection –Patients receiving treatment with a PPI should contact their treating clinician immediately if they develop diarrhea that does not improve • fractures of the hip, wrist, and spine • community-acquired pneumonia • drug interactions (e.g., PPIs inhibit the effects of the antiplatelet drug clopidogrel) –Risk for potentially severe drug interactions should be closely monitored because many patients with GERD receive drugs for other health conditions › Patients who have undergone antireflux surgery should be monitored for adenocarcinoma What Do I Need to Tell the Patient/Patient’s Family? › Educate about GERD, including pathogenesis, risk factors, and long-termmanagement, including details of the prescribed medication regimen › Educate older adult patients about medications (e.g., beta blockers, bisphosphonates) that can decrease LES pressure as a side effect; provide a written list of drugs to avoid, if available, to reinforce verbal education › Educate regarding the importance of making long-term lifestyle modifications, including to • lose weight if overweight and wear loose-fitting clothing around the waist and abdomen • eat small meals and avoid eating for 3 hours before bedtime • avoid lying down for 2 hours following meals • elevate the head of the bed • drink large amounts of water when taking medications • avoid eating foods that they have observed to cause symptom exacerbation of GERD › Educate regarding increased risk for Barrett’s esophagus and the importance of continued medical surveillance of health status
- Bashashati, M., Sarosiek, I., & McCallum, R. W. (2016). Epidemiology and mechanisms of gastroesophageal reflux disease in the elderly: A perspective. Annals of the New York Academy of Sciences, 1380(1), 230-234. doi:10.1111/nyas.13196 (C)
- Ferri, F. F. (2018). Gastroesophageal reflux disease. In F. F. Ferri (Ed.), 2018 Ferri’s clinical advisor: 5 books in 1 (pp. 511-512). Philadelphia, PA: Elsevier. (GI)
- Hallan, A., Bomme, M., Hveem, K., Møller-Hansen, J., & Ness-Jensen, E. (2015). Risk factors on the development of new-onset gastroesophageal reflux symptoms. A population-based prospective cohort study: The HUNT study. American Journal of Gastroenterology, 110(3), 393-400. doi:10.1038/ajg.2015.18 (C)
- Katz, P. O., Gerson, L. B., & Vela, M. F. (2013). Guidelines for the diagnosis and management of gastroesophageal reflux disease. American Journal of Gastroenterology, 108(3), 308-328. doi:10.1038/ajg.2012.444 (G)
- Kennedy-Malone, L. (2014). Abdominal disorders. In L. Kennedy-Malone, K. R. Fletcher, & L. Martin-Plank (Eds.), Advanced practice nursing in the care of older adults (pp. 332-335). Philadelphia, PA: F.A. David Company. (GI)
- Leiman, D. A., Riff, B. P., Morgan, S., Metz, D. C., Falk, G. W., French, B., … Lewis, J. D. (2017). Alginate therapy is effective treatment for gastroesophageal reflux disease symptoms: A systematic review and meta-analysis. Diseases of the Esophagus, 30(2), 1-8. doi:10.1111/dote.12535 (M)
- Patti, M. G. (2017, October 17). Gastroesophageal reflux disease. Medscape. Retrieved May 17, 2018, from http://emedicine.medscape.com/article/176595-overview (GI)
- Petrick, J. L., Nguyen, T., & Cook, M. B. (2016). Temporal trends of esophageal disorders by age in the Cerner Health Facts database. Annals of Epidemiology, 26(2), 151-154.e4. doi:10.1016/j.annepidem.2015.11.004 (R)
- Shaheen, N. J., Weinberg, D. S., Denberg, T. D., Chou, R., Qaseem, A., & Shekelle, P. (2012). Upper en
https://eds-b-ebscohost-com.chamberlainuniversity.idm.oclc.org/eds/pdfviewer/pdfviewer?vid=1&sid=015e150f-7134-466d-8b99-be385202807a%40pdc-v-sessmgr06 Gastroesophageal Reflux Disease in Older Adults: an Overview
• Any change in appetite? Is it a loss of appetite?
• Any change in weight? How much weight gained or lost? Over what time period? Is the weight loss caused by diet?
|Anorexia is a loss of appetite from GI disease as a side effect to some medications, with pregnancy, or with mental health disorders.|
• Any difficulty swallowing? When did you first notice it?
|Dysphagia occurs with disorders of the throat or esophagus.|
|3. Food intolerance
• Are there any foods you cannot eat? What happens if you do eat them: allergic reaction, heartburn, belching, bloating, indigestion?
• Do you use antacids? How often?
|Food intolerance (e.g., lactase deficiency resulting in bloating or excessive gas after taking milk products).
Pyrosis (heartburn), a burning sensation in esophagus and stomach, from reflux of gastric acid.
|4. Abdominal pain|
|• Any abdominal pain? Please point to it.
• Is the pain in one spot, or does it move around?
• How did it start? How long have you had it?
• Constant, or does it come and go? Occur before or after meals? Does it peak? When?
• How would you describe the character: cramping (colic type), burning in pit of stomach, dull, stabbing, aching?
|Abdominal pain may be visceral from an internal organ (dull, general, poorly localized); parietal from inflammation of overlying peritoneum (sharp, precisely localized, aggravated by movement); or referred from a disorder in another site (see Table 21-3, p. 570). Acute pain requiring urgent diagnosis occurs with appendicitis, cholecystitis, bowel obstruction, or a perforated organ.|
|• Is the pain relieved by food or worse after eating?||Chronic pain of gastric ulcers occurs usually on an empty stomach; pain of duodenal ulcers occurs 2 to 3 hours after a meal and is relieved by more food.|
|• Is the pain associated with menstrual period or irregularities, stress, dietary indiscretion, fatigue, nausea and vomiting, gas, fever, rectal bleeding, frequent urination, vaginal or penile discharge?
• What makes the pain worse: food, position, stress, medication, activity?
• What have you tried to relieve pain: rest, heating pad, change in position, medication?
|• Any nausea or vomiting? How often? How much comes up? What is the color? Is there an odor?||Nausea/vomiting is common with GI disease, many medications, and early pregnancy.|
|• Is it bloody?||Hematemesis occurs with stomach or duodenal ulcers and esophageal varices.|
|• Is the nausea or vomiting associated with colicky pain, diarrhea, fever, chills?|
|• What foods did you eat in the past 24 hours? Where? At home, school, restaurant? Is there anyone else in the family with same symptoms in past 24 hours?||Consider food poisoning.|
|• Any recent travel? Where to? Drink the local water or eat fruit? Swimming in public beaches or pools?||GI upset and diarrhea occur when exposed to new local pathogens in developing countries. Water supply may be contaminated.|
|6. Bowel habits|
|• How often do you have a bowel movement?
• What is the color? Consistency?
• Any diarrhea or constipation? How long?
• Any recent change in bowel habits?
• Use laxatives? Which ones? How often do you use them?
|Assess usual bowel habits.
Black stools may be tarry due to occult blood (melena) from GI bleeding or nontarry from iron medications. Gray stools occur with hepatitis.
Red blood in stools occurs with GI bleeding or localized bleeding around the anus.
|7. Past abdominal history|
|• Any history of GI problems: ulcer, gallbladder disease, hepatitis/jaundice, appendicitis, colitis, hernia?
• Ever had any abdominal operations? Please describe.
• Any problems after surgery?
• Any abdominal x-ray studies? How were the results?
|• Which medications are you taking currently?
• How about alcohol—how much would you say you drink each day? Each week? When was your last alcoholic drink?
• How about cigarettes—do you smoke? How many packs per day? For how long?
|Peptic ulcer disease occurs with frequent use of nonsteroidal antiinflammatory drugs (NSAIDs), alcohol, smoking, and Helicobacter pylori infection.|
|9. Nutritional assessment|
|• Now I would like to ask you about your diet. Please tell me all the food you ate yesterday, starting with breakfast.
• Which fresh food markets are located in your neighborhood?
|Nutritional assessment via 24-hour recall (see Chapter 11 for full discussion).
Many inner-city neighborhoods are fresh food “deserts,” lacking produce markets but full of fast-food restaurants.
|Additional History for Infants and Children|
|1. Are you breastfeeding or bottle-feeding the baby? If bottle-feeding, how does baby tolerate the formula?|
|2. Which table foods have you introduced? How does the infant tolerate the food?||Consider a new food as a possible allergen. Adding only one new food at a time to the infant’s diet helps identify allergies.|
|3. How often does your toddler/child eat? Does he or she eat regular meals? How do you feel about your child’s eating problems?
• Please describe all that your child had to eat yesterday, starting with breakfast. Which foods does the child eat for snacks?
|Irregular eating patterns are common and a source of parental anxiety. As long as the child shows normal growth and development and only nutritious foods are offered, parents may be reassured.|
|• Does toddler/child ever eat nonfoods: grass, dirt, paint chips?||Pica: Although a toddler may attempt nonfoods at some time, he or she should recognize edibles by age 2 years.|
|4. Does your child have constipation? How long?|
|• What is the number of stools/day? Stools/week?
• How much water, juice is in the diet?
|• Does the constipation seem to be associated with toilet training?
• What have you tried to treat the constipation?
|5. Does the child have abdominal pain? Please describe what you have noticed and when it started.||Pain is hard to assess with children. Many conditions of unrelated organ systems have vague abdominal pain (e.g., otitis media). They cannot articulate specific symptoms and often focus on “the tummy.” Abdominal pain accompanies inflammation of the bowel, constipation, urinary tract infection, and anxiety.|
|6. For the overweight child: How long has weight been a problem?|
|• At what age did the child first seem overweight? Did any change in diet pattern occur then?
• Describe the diet pattern now.
|Reduced physical activity and food marketing practices contribute to current obesity epidemic.|
|• Do any others in family have a similar problem?||Family history of obesity.|
|• How does child feel about his or her own weight?||Assess body image and social adjustment.|
|Additional History for Adolescents|
|1. What do you eat at regular meals? Do you eat breakfast? What do you eat for snacks?||Adolescent takes control of eating and may reject family values (e.g., skipping breakfast, consuming junk foods and soda pop). The only control parents have is what food is in the house.|
|• How many calories do you figure you consume?||You probably cannot change adolescent eating pattern, but you can supply nutritional facts.|
|2. What is your exercise pattern?||Boys need an average 4000 cal/day to maintain weight; more calories if exercise is pursued. Girls need 20% fewer calories and the same nutrients as boys. Fast food is high in fat, calories, and salt and has no fiber.|
|3. If weight is less than body requirements: How much have you lost? By diet, exercise, or how?||Screen any extremely thin teenager for anorexia nervosa, a serious psychosocial disorder that includes loss of appetite, voluntary starvation, and grave weight loss. This person may augment weight loss by purging (self-induced vomiting) and use of laxatives.|
|• How do you feel? Tired, hungry? How do you think your body looks?||Denial of these feelings is common. Although thin, teen insists that she looks fat, “disgusting.” Distorted body image.|
|• What is your activity pattern?||The anorectic adolescent may have healthy activity and exercise but often is hyperactive.|
|• Is the weight loss associated with any other body change such as menstrual irregularity?||Amenorrhea is common with anorexia nervosa.|
|• What do your parents say about your eating? What do your friends say?||This is a family problem involving control issues. Anyone at risk warrants immediate referral to a physician and mental health professional.|
|Additional History for the Aging Adult|
|1. How do you acquire your groceries and prepare your meals?||Assess risk for nutritional deficit: limited access to grocery store, income, or cooking facilities; physical disability (impaired vision, decreased mobility, decreased strength, neurologic deficit).|
|2. Do you eat alone or share meals with others?||Assess risk for nutritional deficit if living alone; may not bother to prepare all meals; social isolation; depression.|
|3. Please tell me all that you had to eat yesterday, starting with breakfast.||NOTE: 24-hour recall may not be sufficient because daily pattern may vary. Attempt week-long diary of intake. Food pattern may differ during the month if monthly income (e.g., Social Security check) runs out.|
|• Do you have any trouble swallowing these foods?
• What do you do right after eating: walk, take a nap?
|4. How often do your bowels move?|
|• If the person reports constipation: What do you mean by constipation? How much liquid is in your diet? How much bulk or fiber?|
|• Do you take anything for constipation such as laxatives? Which ones? How often?|
|• Which medications do you take?||Consider GI side effects (e.g., nausea, upset stomach, anorexia, dry mouth).|
Documentation and Critical Thinking
States appetite is good with no recent change, no dysphagia, no food intolerance, no pain, no nausea/vomiting. Has one formed BM/day. Takes OTC multivitamins, no other prescribed or over-the-counter medication. No history of abdominal disease, injury, or surgery. Diet recall of past 24 hours listed at end of history.
Inspection: Abdomen flat, symmetric, with no apparent masses. Skin smooth with no striae, scars, or lesions.
Auscultation: Bowel sounds present, no bruits.
Percussion: Tympany predominates in all 4 quadrants, liver span is 8 cm in right MCL. Splenic dullness located at 10th intercostal space in left midaxillary line.
Palpation: Abdomen soft, no organomegaly, no masses, no tenderness.
Healthy abdomen; bowel sounds present
Jarvis, C. Physical Examination and Health Assessment. [VitalSource Bookshelf]. Retrieved from https://online.vitalsource.com/#/books/9781455728107/
|Foods That Triggers GERD|
|Chocolate, spearmint, peppermint, decaffeinated coffee, high-fat or high-carbohydrate meals, alcohol||Decrease LES tone|
|Acidic foods, citrus fruit and juices, caffeine||Increase gastric acid secretion|
|Fatty foods||Delay gastric emptying|
|Tobacco||Decreases LES tone and increases gastric acid secretion|
|Anticholinergics, theophylline, meperidine, calcium channel blockers||Decrease LES tone|
|Bethanechol, metoclopramide, pentobarbital, histamine, antacids||Increase LES tone|
Signs and Symptoms
Most patients complain of burning substernal pain that radiates upward, often aggravated by meals and by lying down and relieved by sitting up. The burning substernal pain can be confused with the chest pain associated with angina or myocardial infarction and cause considerable patient distress. Nocturnal aspiration of reflux contents can cause recurrent pneumonia, bronchospasm, and cough.
Sore throat, hoarseness, and halitosis are associated with reflux into the back of the throat. A reflex salivary hypersecretion is sometimes described, especially in children.
Dysphagia usually suggests long-standing GERD with acute inflammation, stricture, or both. Solid food may stick in the distal esophagus; repeated swallows and significant amounts of liquid may be required to ensure passage into the stomach.
Table 34-2 shows the signs and symptoms of GERD and potential complications. A predominance of heartburn, regurgitation, or both, occurring after meals (particularly large or fatty meals) are highly specific to GERD. Older adults, who may have decreased gastric acidity or decreased pain perception, may not report these symptoms despite significant disease. They are also more likely to self-treat. Infants and children also have slightly different signs and symptoms and they are discussed in the sections about these specific patient populations.
Table 34-2 Signs and Symptoms of GERD and Potential Complications
Source: Adapted from VHA/Department of Defense. (2003). Clinical practice guideline for management of adults with gastroesophageal reflux disease in primary care practice. Washington, DC: Author.
Signs and symptoms alone are rarely sufficient to diagnose GERD; however, guidelines differ on their recommendations for diagnostic testing. The American College of Gastroenterology (ACG) guidelines recommends no routine testing for straightforward GERD (Katz et al, 2013). The ACG recommends diagnostic testing if patients do not respond to twice-daily proton pump inhibitors (PPIs), or gastric malignancy or misdiagnosis is a concern. The ACG (2013) recommends endoscopy for elderly patients, those with noncardiac chest pain, those at risk for Barrett’s esophagitis, and those nonresponsive to PPIs (Katz et al). The ACG guidelines indicate “alarm symptoms” of melena, persistent vomiting, dysphagia, hematemesis, anemia, or involuntary weight loss greater than 5% that warrant endoscopy. Diagnostic testing is done by a gastroenterology specialist. The treatment protocol presented here assumes appropriate diagnosis of GERD.
Each of the contributing factors to the development of GERD is a target for pharmacological management. Drugs can be used to increase LES tone, to reduce the amount of acid in the chyme, to improve peristalsis and thereby decrease the time chyme is available to produce reflux, and to decrease the exposure of the mucosa to highly acid material. The classes of drugs with these actions include antacids, histamine2 blockers, cytoprotective agents, prokinetics, and PPIs. Figure 34-1 depicts the site of action of each of these classes of drugs.
Drugs to Improve Lower Esophageal Sphincter Tone
Metoclopramide and bethanechol improve LES tone and have a prokinetic function but are not considered for monotherapy in the treatment of GERD. They are most useful in combination with acid suppression for patients with gastroparesis. Metoclopramide and bethanechol have not demonstrated significant healing of esophageal lesions.
Antacids also serve a dual purpose: they improve LES tone and increase gastric pH. They are usually patient-initiated drug therapy, along with lifestyle modifications.
Drugs to Reduce the Amount of Acid
Two main classes of drugs are used to reduce acid secretion: histamine2 receptor antagonists (H2RAs) and PPIs. H2RAs act on the parietal cells to decrease the amount of acid produced. Because most of these drugs are available OTC, many patients may have used these drugs as self-initiated therapy before seeking care. Providers need to determine self-medication for GERD in the initial history. H2RAs may be used as maintenance acid suppression or heartburn therapy in patients who do not have erosive GERD (Katz et al, 2013). The ACG guidelines recommend a trial of nighttime H2RAs for patients taking daytime PPIs to treat nighttime reflux (Katz et al, 2013).
Figure 34-1. Sites of action of drugs used to treat GERD and PUD.
PPIs are standard first-line therapy for GERD and decrease acid secretion by almost 100%. PPIs improve esophageal healing to about 80%.
Drugs to Improve Peristalsis
A few patients continue to report symptoms despite reduced acid secretion. These patients may benefit from prokinetics, which improve both LES tone and peristalsis. Metoclopramide may provide some benefit but has limited usefulness because of adverse drug reactions.
Drugs to Decrease Mucosal Exposure
Two cytoprotective agents are available to decrease the exposure of the gastric mucosa to acid: sucralfate (Carafate) and misoprostol (Cytotec). Sucralfate acts largely as a Band-Aid to cover sites having erosive damage but is more often used with ulcers. Misoprostol acts by increasing the production of cytoprotective mucus. Older adults or those taking multiple drugs may benefit from sucralfate. Misoprostol is reserved largely for use when NSAIDs are a contributing factor to the increased acid load. These drugs are not mentioned in GERD guidelines, although discontinuance of NSAIDs is mentioned.
The pharmacokinetics and pharmacodynamics of each of the categories of drugs are discussed in more detail in Chapter 20.
Goals of Treatment
Therapy for patients with GERD has four goals: (1) reduce or eliminate the symptoms; (2) heal any esophageal lesions; (3) manage or prevent complications such as stricture, Barrett’s esophagus, or esophageal carcinoma; and (4) prevent relapse. Meeting these goals requires a combination of lifestyle modification and drug therapy.
Rational Drug Selection
For most patients, GERD is treated with PPI therapy. Figure 34-2 presents an algorithm for GERD treatment.
Antireflux maneuvers, dietary changes, and cessation of smoking are central to the management of GERD regardless of the step. Antireflux maneuvers reduce back pressure on the LES from intra-abdominal contents. Dietary changes reduce the total volume and acid content of the stomach. Smoking reduces LES tone and increases gastric acid secretion. Box 34-1 lists appropriate lifestyle modifications.
Lifestyle modifications and OTC antacids are a logical first step for treatment of heartburn, dyspepsia, or mild nonerosive GERD. Most patients have tried an OTC antacid before they seek health care. This step alone may be sufficient. H2RAs may be sufficient if symptoms are mild and no erosive disease is evident. Tachyphylaxis may occur with H2RAs.
PPIs are first-line therapy for patients with moderate or severe GERD or erosive disease. PPI therapy continues for 8 weeks and 70% to 80% of patients should have complete relief with PPIs (Katz et al, 2013). There are no major differences in response between the PPIs (Katz et al, 2013). Maintenance PPI therapy should be prescribed for patients who have symptoms that recur after PPI therapy is discontinued or patients with complications such as erosive esophagitis or Barrett’s esophagitis (Katz, et al). The patient should be reassessed in 6 to 12 months to determine if he or she can be weaned off therapy. Patients who do not respond to PPIs need to be referred to a gastroenterology specialist.
Patient variables are also considered in treatment choices. Primary among them is the age of the patient.
Figure 34-2. Algorithm for gastroesophageal reflux disease (GERD).
BOX 34-1 LIFESTYLE MODIFICATIONS IN GERD MANAGEMENT FOR ADULTS
- Sleep with the head of the bed elevated 6 to 8 inches with bed blocks or wedges or by using a hospital bed.
- Avoid the recumbent position within 3 hours after eating.
- Avoid bending over within 3 hours after eating.
- Avoid exercise, especially strenuous exercise, within 3 hours after eating.
- Attain and maintain appropriate body weight.
- Avoid spicy, acidic, tomato-based, or fatty foods.
- Avoid chocolate, peppermint, onions, and citrus fruits and juices.
- Limit your intake of coffee, tea, alcohol, and colas.
- Eat moderate amounts of food at each meal. Do not gorge yourself.
- Avoid eating meals or bedtime snacks within 3 hours of going to bed.
- Reserve fluid intake for after or between meals.
- Stop smoking. Smoking both lowers LES tone and increases the secretion of gastric acid.
- Smoking cessation is a high priority.
- Weight loss may improve symptoms
Woo, T. M., Robinson, M. V. Pharmacotherapeutics For Advanced Practice Nurse Prescribers. [VitalSource Bookshelf]. Retrieved from https://online.vitalsource.com/#/books/9780803658110/