GERD pharmacy information 2024-2023..pdf

GERD pharmacy information 2024-2023..pdf

1. Gastroesophageal
Reflux Disease
Arthur Harris, M.D.
GI Division, Jacobi Medical Center/NCBH
Assistant Professor of Medicine, AECOM

2. Objectives
Definition of GERD
Epidemiology of GERD
Pathophysiology of GERD
Clinical Manifestations
Diagnostic Evaluation
Treatment
Complications

3. Definition
American College of
Gastroenterology (ACG)
Symptoms OR mucosal
damage produced by the
abnormal reflux of gastric
contents into the
esophagus
Often chronic and relapsing
May see complications of
GERD in patients who lack
typical symptoms

4. Physiologic vs Pathologic
Physiologic GERD
Post-prandial
Short-lived
Often asymptomatic
TLSER’s
No nocturnal sx
Pathologic GERD
Symptoms
Mucosal injury
Nocturnal sx

6. Epidemiology
About 44% of the US adult
population have heartburn at least
once a month
14% of Americans have symptoms
weekly
7% have symptoms daily

7. Pathophysiology
Primary barrier to
gastroesophageal
reflux is the lower
esophageal sphincter
LES normally works in
conjunction with the
diaphragm
If barrier disrupted,
acid goes from
stomach to esophagus

8. Clinical Manifestations
Most common symptoms
Heartburn—retrosternal burning
discomfort
Regurgitation—effortless return of
gastric contents into the pharynx
without nausea, retching, or
abdominal contractions

9. Clinical Manifestations
Dysphagia—difficulty swallowing
Other symptoms include:
Chest pain, water brash, globus sensation,
odynophagia, nausea
Extraesophageal manifestations
Asthma, laryngitis, chronic cough

10. Diagnostic Evaluation
If classic symptoms of heartburn and
regurgitation exist in the absence of
“alarm symptoms” the diagnosis of
GERD can be made clinically and
treatment can be initiated

11. Potential Oral and Laryngopharyngeal Signs
Associated with GERD
Edema and hyperemia
of larynx
Vocal cord erythema,
polyps, granulomas,
ulcers
Hyperemia and
lymphoid hyperplasia
of posterior pharynx
Interarytenyoid
changes
Dental erosion
Subglottic stenosis
Laryngeal cancer

12. Alarms
Alarm Signs/Symptoms
Dysphagia
Early satiety
GI bleeding
Odynophagia
Vomiting
Weight loss
Iron deficiency anemia

13. Trial of Medications
H2RA or PPI
Expect response in 2-4 weeks
If no response
Change from H2RA to PPI
Maximize dose of PPI

14. Trial of Medications
If PPI response inadequate despite
maximal dosage
Confirm diagnosis
EGD
24 hour pH monitoring

15. Esophagogastrodudenoscopy
Endoscopy (with biopsy if
needed)
In patients with alarm
signs/symptoms
Those who fail medication trial
Those who require long-term Rx
Lacks sensitivity for
identifying pathologic reflux
Absence of endoscopic
features does not exclude a
GERD diagnosis
Allows for detection,
stratification, and
management of esophageal
manifestations or
complications of GERD

16. Ambulatory pH Testing
24-hour pH monitoring
Accepted standard for establishing or
excluding presence of GERD for those
patients who do not have mucosal
changes
Trans-nasal catheter or a wireless,
capsule shaped device

17. Ambulatory 24 hour pH Monitoring -1
Physiologic study
Quantify reflux in
proximal/distal
esophagus
% time pH < 4
DeMeester score
Symptom
correlation

18. Ambulatory 24 hour pH Monitoring -2
Normal
GERD

19. Wireless, Catheter-Free Esophageal pH Monitoring
Potential Advantages
●Improved patient
comfort and acceptance
●Continued normal
work, activities and diet
during study
●Longer reporting
periods possible (up to
48 hours)
●Maintain constant
probe position relative to
SCJ

20. Esophageal Manometry
Limited role in GERD
Assess LES
pressure, location
and relaxation
Assist placement of
24 hour pH catheter
Assess peristalsis
Prior to anti-reflux
surgery

21. Patient with heartburn
Initiate Rx with H2RA or PPI
H2RA taken
BID
Good response
Frequent relapses
On demand Rx
PPI taken QD
Good response
Maintenance therapy
with lowest effective dose
Symptoms persist
Consider EGD if
risk factors present
(> 45, white, male
and > 5 yrs of sx)
Increase to
max dose QD
or BID
Good response
Confirm diagnosis
EGD, ph monitor
No
Yes
Yes
No
Yes
Yes
No
No

22. GERD vs Dyspepsia
Distinguish from Dyspepsia
Ulcer-like symptoms-burning, epigastric
pain
Dysmotility like symptoms-nausea,
bloating, early satiety, anorexia
Distinct clinical entity
In addition to anti-secretory meds
and an EGD, need to consider testing
for Helicobacter pylori

23. Treatment
Goals of therapy
Symptomatic relief
Heal esophagitis
Avoid complications

24. Better Living
Lifestyle modifications
Avoid large meals
Avoid acidic foods (citrus/tomato), alcohol, caffeine,
chocolate, onions, garlic, peppermint
Decrease fat intake
Avoid lying down within 3-4 hours after a meal
Elevate head of bed 4-8 inches
Avoid meds that may potentiate GERD (CCB, alpha
agonists, theophylline, nitrates, sedatives, NSAID’s)
Avoid clothing that is tight around the waist
Lose weight
Stop smoking

25. Treatment
Antacids
O-T-C acid
suppressants and
antacids may be
appropriate initial
therapy
Approx 1/3 of patients
with heartburn-related
symptoms use at least
twice weekly
More effective than
placebo in relieving
GERD symptoms

26. Treatment
Histamine H2-Receptor Antagonists
More effective than placebo and
antacids for relieving heartburn in
patients with GERD
Faster healing of erosive esophagitis
when compared with placebo
Can use regularly or on-demand

27. Treatment
AGENT EQUIVALENT DOSAGE
DOSAGES
Cimetadine 400mg twice daily 400-800mg twice daily
Tagamet
Famotidine 20mg twice daily 20-40mg twice daily
Pepcid
Nizatidine 150mg twice daily 150mg twice daily
Axid
Ranitidine 150mg twice daily 150mg twice daily
Zantac

28. Treatment
Proton Pump Inhibitors
Better control of symptoms with PPI’s vs
H2RAs and better remission rates
Faster healing of erosive esophagitis
with PPIs vs H2RAs

29. Treatment
AGENT EQUIVALENT DOSAGE
DOSAGES
Esomeprazole 40mg daily 20-40mg daily
Nexium
Omeprazole 20mg daily 20mg daily
Prilosec
Lansoprazole 30mg daily 15-30mg daily
Prevacid
Pantoprazole 40mg daily 40mg daily
Protonix
Rabeprazole 20mg daily 20mg daily
Aciphex

30. Treatment
H2RAs vs PPI’s
12 week freedom from symptoms
48% vs 77%
12 week esophagitis healing rate
52% vs 84%
Speed of healing
6%/wk vs 12%/wk

31. Treatment Modifications for Persistent Symptoms
Improve compliance
Optimize pharmacokinetics
Adjust timing of medication to 15 – 30 minutes
before meals (as opposed to bedtime)
Allows for high blood level to interact with
parietal cell proton pump activated by the meal
Consider switching to a different PPI

32. Treatment
Anti-reflux surgery - Indications
Failed medical management
Patient preference
GERD complications
Medical complications attributable to a
large hiatal hernia
Atypical symptoms with pathologic
reflux documented on 24-hour pH
monitoring

33. Treatment
Anti-reflux surgery candidates
EGD proven esophagitis
?Normal esophageal motility
Incomplete response to acid suppression

34. Treatment
Anti-reflux surgery (laparoscopic)
Tenets of surgery
Reduce hiatal hernia
Repair diaphragm
Strengthen GE junction
Strengthen anti-reflux barrier via gastric wrap
75-90% effective at alleviating symptoms of
heartburn and regurgitation

36. Treatment
Post-surgery
10% have solid food dysphagia
2-3% have permanent symptoms
7-10% have gas, bloating, diarrhea,
nausea, early satiety
Within 3-5 years, up to 52% of patients
back on anti-reflux medications

37. Treatment
Endoscopic treatment
Relatively new
No clearly established indications
Well-informed patients with well-documented
GERD responsive to PPI therapy may benefit
Three categories
Radiofrequency application to increase LES reflux
barrier
Endoscopic sewing devices
Injection of a non-resorbable polymer into LES
region

38. Complications
Erosive esophagitis
Stricture
Barrett’s esophagus

39. Complications
Erosive esophagitis
Responsible for 40-60% of GERD
symptoms
Severity of symptoms often fail to
match severity of erosive esophagitis

40. Complications
Esophageal
stricture
Occurs as a
result of healing
of erosive
esophagitis
May need
dilation

41. Peptic Stricture
Barium swallow
Endoscopy

42. Complications
Barrett’s Esophagus
Columnar metaplasia
of the esophagus
Associated with the
development of
adenocarcinoma

43. Complications
Barrett’s Esophagus
Acid damages lining of
esophagus and causes
chronic esophagitis
Damaged area heals in
a metaplastic process
with abnormal columnar
cells replacing
squamous cells
This specialized
intestinal metaplasia
can progress to
dysplasia and
adenocarcinoma

44. Complications
Patient’s who need EGD
Alarm symptoms
Poor therapeutic response
Long symptom duration
“Once in a lifetime” EGD for patient’s
with chronic GERD becoming accepted
practice
Many patients with Barrett’s are
asymptomatic

45. Complications
Barrett’s Esophagus
Manage in same manner as GERD
EGD every 3 years in patient’s without
dysplasia
In patients with dysplasia, annual to
even shorter interval surveillance is
recommended

46. Summary
Definition of GERD
Epidemiology of GERD
Pathophysiology of GERD
Clinical Manifestations
Diagnostic Evaluation
Treatment
Complications

47. ?QUESTIONS?