Gastroesophageal Reflux Disease

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
Clinical or histological disorder resulting from gastric materials “refluxing” into the esophagus
This reflux causes a breakdown of the esophageal mucosa
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.
Causes of esophageal mucosa breakdown:
Transient/spontaneous LES relaxation
Transient increase in intra-abdominal pressure
LES tone can be caused by certain foods, drugs, hormones, or other physiologic factors
Classic Symptoms: “Heartburn”
Hypersalivation, belching, and regurgitation especially after a large meal
Antacids are commonly used to treat this symptoms
Chronic cough, hoarseness, pharyngitis, and angina like pain
Non-allergic asthmatic symptoms have been reported
Continual pain, dysphagia, bleeding, weight loss, choking and chest pain
Differentiate from MI or Angina Pain
Alleviate pain and discomfort associated with the symptoms of GERD
Decrease frequency and duration of reflux
Often used as monotherapy in mild or intermittent heartburn from GERD
May be used in mild cases if uncontrolled from non-pharmacologic treatment alone
Accompanied by non-pharmacologic treatment
2) Avoid large meals and aggravating foods
Indicated for mild, intermittent reflux
Life-style modifications (Non-pharmacologic therapy)
Antacids or OTC H2-antagonists as needed
Mild to moderate, typical symptoms not relieved by Step 1 treatment or Atypical symptoms
Prescription H2 Antagonists, proton pump inhibitors or Prokinetic agents
Moderate to severe symptoms or those with erosive disease
Higher dosed H2 antagonists or Proton Pump Inhibitors
Reconstruction of lower esophageal sphincter
Indicated for patients with moderate to severe symptoms or those with erosive disease
Indicated last line when drug therapy has failed
Not indicated for the elderly population
Drug efficacy vs. Therapeutic Outcomes
Many interaction with some agents and less with others
Weigh the advantages & disadvantages of each
High cost can cause compliance issues
Competitive Equilibrium Antagonist at the H2 Receptor resulting in a block of acid secretion
2 separate drug molecules bind covalently to the proton pump and inhibit its acid secreting ability
Forms a gel which has high affinity for an ulcerated site and protects that site from the acidic envirionment of the stomach
Increases gastric motility to speed up digestive process which decreases reflux occurrence
Weak bases which neutralize the stomach acid and decrease reflux
SE = Diarrhea, HA, Skin rash, dizziness
Many drug interactions due to cyp450 inhibition
Dosage adjustments are needed for patients with renal and hepatic dysfunction
SE = HA, dizziness, diarrhea, constipation
Very few drug interactions have been reported
No dose adjustment needed for patients with hepatic dysfunction
SE = Fatigue, dizziness, HA, GI discomfort
Interactions with Procainamide, Diazepam, and Warfarin have been reported
No dose adjustment is required for patients with hepatic dysfunction
SE = HA, dizziness, diarrhea, abdominal pain, nausea, vomiting
Omeprazole increases the concentrations of Benzodiazepines, phenytoin, and warfarin
Clarithromycin and Sucralfate will decrease Omperazole concentrations
Dose adjustment required for patients with liver impairment but not for renal impairment
Lansoprazole decreases theophyline concentrations
Sucralfate decreases Lansoprazole levels
Dose adjustment for liver dysfunction patients but not for renal patients
Dose = 1 gram QID on an empty stomach
No dosage adjustments needed for kidney or liver impaired patients
SE = Restlessness, drowsiness, fatigue
Dosage adjustment are required for renally impaired patients
No adjustment needed in hepatic impairment
Decreases signs and symptoms of GERD
Hypersensitivity reactionsex. Rash
Side effects to the specific agent being used
Bibliography:

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