GASTROESOPHAGEAL REFLUX DISEASE (GERD) Caday, Justine Audrey Pontipedra, Quennie Samoza, Emeral Shaine Sotomango, Janella Louis GROUP 2 WHAT IS GERD? Gastroesophageal reflux disease (GERD) occurs when stomach acid frequently flows back into the tube connecting your mouth and stomach (esophagus). This backwash (acid reflux) can irritate the lining of your esophagus. GENERAL INFORMATION • George Anderson is a 58-year-old man who presents to the community pharmacy with complaints of heartburn and episode of regurgitation. CHIEF COMPLAINT “I’m having a lot of heartburn, especially after eating. These pills and liquids I’ve tried seem to work for a little while, but then they wear off”. History of Present Illness • George Anderson is a 58-year-old man who presents to the community pharmacy with complaints of heartburn four to five times a week over the last 4 months. • This also includes episodes of regurgitation, after which he is left with an acidic taste in his mouth. • The heartburn and regurgitation often occur after meals, but there are times when he experiences these symptoms between meals. • He reports no difficulty swallowing food or liquids. • He tried Extra Strength Maalox liquid first and then Pepcid AC tablets, both of which were recommended by his coworkers. • The Maalox provided some relief, but he had to take it several times a day. He took the Pepcid AC 10 mg twice daily for 1 week. This worked intermittently but didn’t provide enough relief. PAST MEDICAL HISTORY • HTN × 12 years • CKD × 2 years • Type 2 DM × 5 years SOCIAL HISTORY • Patient is married with two children. He works as an information technology specialist for a large corporation. He drinks one to two beers a day after work, 4–5 days per week. He has a 25 pack-year history of tobacco use and currently smokes 1 ppd. MEDS • Amlodipine 5 mg once daily • Glyburide 5 mg twice daily • Aspirin 81 mg daily • Ibuprofen 200–400 mg PRN for headaches and pain REVIEW OF SYSTEM • Patient reports occasional tension headaches but no visual changes, aura, or dizziness. • frequent episodes of a burning pain that starts in his stomach area and travels up his chest but does not radiate to his back or arms; this is usually associated with an acidic taste in his mouth • dark/tarry stools • reports some mild ankle swelling in both ankles; he has gained approximately 8 pounds over the last 6 months. PROBLEM LIST • Heartburn four to five times a week. • Episodes of regurgitation • The heartburn and regurgitation often occur after meals, but there are times when he experiences these symptoms between meals. SUBJECTIVE • Lot of heartburn, especially after eating. • After regurgitation he is left with an acidic taste in his mouth. • Symptoms wake him up at night approximately once a week. • Burning pain that starts in his stomach area and travels up his chest but does not radiate to his back or arms. OBJECTIVES Vital signs of patient BLOOD PRESSURE 149/89 mmHg PULSE 87 bpm RESPIRATORY RATE 17 per min TEMPERATURE 36°C WEIGHT 99 kg HEIGHT 5’10” OBJECTIVES CONT. PHYSICAL EXAMINATION General appearance Well-developed African-American man in NAD HEENT PERRLA; EOMI; moist mucous membranes; intact dentition; oropharynx clear Abd Obese; NT/ND; (+) BS; (–) HSM Neck/lymph node Trachea midline; (–) thyromegaly; (–) lymphadenopathy; (–) JVD Lungs/Thorax CTA bilaterally Genital/Rect Prostate size WNL; (–) tenderness Heme (–) brown stool Skin No lesions or rashes ASSESSMENT PATIENT’S LAB TEST Na 138 mEq/L 135-145 K 4.8 mEq/L 3.5 to 5.5 mEq/L Cl 108 mEq/L 96 and 106 CO2 21 mEq/L 22 to 29 mEq/L BUN 18 mg/dL 7 to 20 mg/dL SCr 1.9 mg/dL 0.9 to 1.3 mg/dL for adult males Fasting Glu 200 mg/dL less than 140 mg/dL Phos 4.1 mg/dL 2.5-4.5 mg/dL Ca 8.9 mg/dL 8.6 to 10.3 mg/dL Hgb 14 g/dL Male: 13.8 to 17.2 Female: 12.1 to 15.1 Hct 42% men 41% to 50% women 36% to 48% RBC 4.6 × 106 /mm3 men – 4.7 to 6.1 (cells/mcL) women – 4.2 to 5.4 million cells/mcL. Plt 400 × 103 /mm3 150 to 400 × 109/L A1C 8.6% below 5.7% AST 21 IU/L 5 to 40 units per liter of serum ALT 24 IU/L 7 to 56 units per liter of serum. WBC 8.7 ×103 /mm3 4.5 to 11.0 × 109/L Fasting Lipid Panel: TC 230 mg/dL Less than 200 mg/dL (5.18 mmol/L) LDL 146 mg/dL less than 100 mg/dL. TG 187 mg/dL Less than 150 milligrams per deciliter (mg/dL), HDL 39 mg/dL 60 mg/dL (1.6 mmol/L) or above PROBLEM IDENTIFICATION Develop a list of this patient’s drug therapy problems. Maalox －Patient had to take this med several times daily but it is only recommended usually after meals and at bedtime as needed. Adult dose: 10-20ml 4 times daily. Pepcid AC tablet - If you are using nonprescription famotidine for selftreatment of acid indigestion or heartburn, take 1 tablet by mouth with a glass of water as needed. Do not use more than 2 tablets in 24 hours unless directed by your doctor. • Other non-steroidal anti-inflammatory drugs PROBLEM IDENTIFICATION Classify the GERD symptoms this patient is experiencing. Are they typical or atypical in nature? Are any alarm symptoms present? • Heartburn - four to five times a week over the last 4 months. • Episodes of regurgitation Both are typical symtoms. PROBLEM IDENTIFICATION cont. What factors could be contributing to the development of GERD symptoms in this patient? • He drinks alcoholic beverages 4 to 5 days per week over the last 4 months. • Tobacco use • Obesity • NSAID PROBLEM IDENTIFICATION cont. What factors would cause you to refer this patient for immediate diagnostic evaluation versus recommending empiric drug therapy? • Frequent episodes of a burning pain that starts in his stomach area. • Having a lot of heartburn PROBLEM IDENTIFICATION cont. What diagnostic approaches could be used to evaluate and confirm a diagnosis of GERD? • Endoscopy • Upper GI Series • Manometry • pH Monitoring/ Impedance • Clinical history DESIRED OUTCOME Develop a list of pharmacotherapeutic goals for this patient. • Alleviate or eliminate the patient’s symptoms, • Decrease the frequency or recurrence and duration of gastroesophageal reflux, • Promote healing of the injured mucosa, and • Prevent complications THERAPEUTIC ALTERNATIVES a. What lifestyle modifications or nonpharmacologic therapies may improve this patient’s GERD symptoms? • Patient should be educated about include weight lose in obese patient • Consumption of smaller meals and not sleeping for at least 3 hours after eating. • Avoidance of food or medications that exacerbate GERD. • Elevation of the head end of the bed. b. What drug therapies could be used to treat this patient’s GERD symptoms? The Proton pump inhibitors (PPIs) - one of the most effective medications for relieving GERD symptoms. Lansoprazole - reduces the amount of acid your stomach makes. OPTIMAL PLAN Develop a complete treatment plan for managing this patient’s GERD symptoms. Lifestyle modification Acid suppression therapy Weight loss in overweight GERD patients. Patients presenting with moderate-to-severe symptoms should be started on a PPI as initial therapy Elevation of the head end of the avoidance of food 2-3 hrs. before bedtime if nocturnal GERD symptoms present. For delayed-release PPIs should be administered 30-60 minutes before meals. Avoid fatty food, alcohol, peppermint, chocolate. And spearmint. Patients with nocturnal symptoms may benefit from taking PPI prior to the evening meal. Include protein rich meals in diet. Lansoprazole (Prevacid 24hr) 15 mg once daily for 2 weeks. Stop smoking. Take drugs in the sitting upright or standing position and with plenty of water, especially those that have a direct irritant effect on the esophageal mucosa. OUTCOME EVALUATION What parameters should be monitored to assess both the efficacy and toxicity of your selected drug regimen? • Patients should be monitored for adverse drug reactions. • Drug-drug interactions should also be assessed and these agents should be avoided if possible. • The frequency and severity of symptoms should be monitored. • Patients should be counseled on symptoms that suggest the presence of complications requiring immediate medical attention, such as dysphagia. • Patients should also be monitored for the presence of extraesophageal symptoms. PATIENT EDUCATION How will you educate the patient about his GERD therapy to enhance compliance, minimize adverse effects, and promote successful therapeutic outcomes? Simple lifestyle changes may help relieve the symptoms of GERD. These include: • Do not smoke • Stop drinking alcoholic drinks • DO not consume foods that irritate the esophagus. • It is helpful to eat small meals throughout the day instead of large meals. • The patient should avoid eating before bedtime or lying down after you eat. It can be helpful to raise the head of your bed six inches. • Additionally, The patient should maintain a healthy weight and good posture. PHARMACIST CAREPLAN Health care needed Pharmacothe Recommenda Monitoring Parameters rapeutic goal tions Desired end point • • • To manage the patients difficulty in breathing and excessive heartburn. • relief of symptoms prevention of symptom relapse • PPI is the most effective medication for relieving GERD symptoms. • Monitor patients condition and prescribed medications. • Lifestyle modification • Undergo Lab test to determine patients improvement. • Educate patients about his condition. Eliminate heartburn and regurgitation of the patient while maintaining the normal function of lower esophageal sphincter and preservation of the esophageal tissue.
