Each year there are millions of individuals suffering from acid reflux.
It is a chronic disease of the digestive system known as gastroesophageal reflux disease (GERD) that irritates and affects the tissue of the esophagus (Badillo & Francis, 2014). It is a condition in which the fluid content of the stomach backs up or refluxes into the esophagus causing symptoms such as acid regurgitation, chest or epigastric pain, indigestion, nausea, bloating, and belching (Badillo & Francis, 2014). Many individuals may have heartburn, indigestion or acid regurgitation from a period which weakens the esophageal sphincter and can be triggered by several factors such as smoking, wearing tight clothing around the middle, pregnancy, overweight as well as certain drinks and foods.
Some of the common foods and drinks that can cause symptoms of heartburn are spicy, fried, fatty foods, chocolate, citrus, coffee, carbonated beverages, and drinks with alcohol (Jarosz & Taraszewska, 2014). Also, some medications can cause GERD; this may include alpha blockers, anti-inflammatories, and nitrates (Jarosz & Taraszewska, 2014). Fortunately, many individuals can manage and treat the discomfort of GERD with certain lifestyle modifications and over-the-counter agents.
If lifestyle changes and medications are unable to help provide discomfort, then surgery may be another option if it is too severe to be managed with the interventions suggested.In this case, the author identifies a case scenario of a 60-year-old woman, presenting to the office with complaints of heartburn, occurring mainly after eating and especially at night. She reports experiencing nausea, regurgitation, and severe burning in her chest after eating spicy food. She has a history of asthma and osteoporosis, and six months earlier she fractured her hip after a fall. After a complete physical examination and referral for tests to rule out other causes, the patient was diagnosed with gastroesophageal reflux disease (GERD).
In this paper, the author will provide effective nonpharmacological and pharmacological treatment options, the drug action and use prescribed, its drug absorption, metabolism, distribution, and excretion. The selected prescribed drug adverse effects, contraindications, precautions, drug to drug interactions, drug to food interactions, and drug to herb interactions. As well as the drug administration guidelines, monitoring parameters, clinical drug dosing and patient education. Pharmacological and Nonpharmacological Treatment OptionsIn this case scenario, Ms. Jones has been recently diagnosed with GERD based on the symptoms affecting her quality of life.
Therefore, the need for nonpharmacologic and pharmacological interventions can both benefit her in providing relief and comfort. Research shows that the first line of treatment for individuals with GERD is agents in the class of a proton pump inhibitors (PPI) such as omeprazole, pantoprazole, lansoprazole, esomeprazole, etc. with initiating at a low dose (Kahrilas, 2018). Although these class of drugs provides effective results, there is an increased risk of fractures when taken for a long period. In the case of Ms. Jones fracturing her hip six months ago due to a fall and history of osteoporosis will contraindicate the recommendation of PPI utilization unless all other alternatives have failed.
Based on the patient diagnosis and history, an effective pharmacologic treatment option can be helpful in managing her GERD condition. This treatment option will start with a step-up approach as her symptoms are intermittently transpiring after eating spicy food, especially at night. The healthcare provider would first discuss with the patient in depth about the patient’s symptoms regarding the existence of the heartburn, permanence, and various treatment options available. It is essential that both the provider and patient agree on a treatment plan that will be suitable for the patient to be committed to so that the best care is provided.
It is important to educate the patient about nonpharmacological interventions such as lifestyle modifications that can alleviate the symptoms. This may consist of instructing the patient to abstain from eating spicy food especially late at night, refraining from eating or drinking anything that may trigger the symptoms, weight loss, limiting alcohol intake, and avoid tobacco use (Kahrilas, 2018). The patient can benefit from eating two to three hours before bedtime, sit up for an hour after eating, head of the bed elevated at night with pillows, avoid tight-fitting clothes, avoiding acidic drinks, and eating smaller meals (Kahrilas, 2018).The provider would recommend initiating the patient with histamine two receptor antagonist (H2RAs) as an effective treatment because it works by hindering H2 receptors in the parietal cell, to decrease acid production (Kahrilas, 2018). An example of a drug in this class is famotidine (Pepcid), Ranitidine (Zantac), etc. which should be taken thirty to sixty minutes before a meal or predicted heartburn/reflux along with nonpharmacological treatment options for the first few weeks then reassess. If the symptom is relieved with the prescribed H2RA agent, then the patient should continue this as needed therapy. If not, then other alternatives may be required for relief from the symptoms of GERD.
Ms. Jones has also identified having a history of osteoporosis and recent fall. Therefore she can also benefit with taking supplemental medications such as calcium that will help increase bone strength. The use of antacids would be valuable such as the use of calcium carbonate because it neutralizes stomach acid and provides calcium. However, the patient would need to separate dosing from other medications by at least two hours to avoid interaction and would require being taken after meals, and at bedtime, hence this may not be suitable for this patient. Therefore, H2RAs may be the preferred option at this time along with the nonpharmacological interventions previously identified.
Drug Action and UseHistamine2 blockers also known as histamine two antagonists (H2RAs) inhibit and reduce gastric acid secretion with the interaction between histamine and H2 receptors located on the parietal cells of the stomach (Woo ; Robinson, 2016; Maradey-Romero ; Fass, 2014). H2RAs are used to reduce gastric acid in patient’s prophylaxis, manage duodenal and gastric ulcers and GERD that is used to treat heartburn, acid indigestion, and sour stomach (Woo & Robinson, 2016). The utilization of H2RAs is also effective in preventing postprandial heartburn if given thirty minutes before a meal, as well as if given at bedtime will significantly reduce the duration of a nocturnal acid breakthrough. The pharmacodynamics of famotidine is illustrative of the overall mechanism of action of histamine blockers (Woo & Robinson, 2016).Drug Absorption, Metabolism, Distribution, ExcretionThe drugs in the class of the H2RAs are absorbed well with oral administration and can enter breast milk and cerebrospinal fluid.
Each agent is metabolized differently by the CYP450 enzyme system of the liver and excreted in different percentage as unchanged drug in the urine (Woo & Robinson, 2016). The onset of famotidine is within one hour after oral administration, the peak effect and duration is achieved within one to four hours. The protein binding is fifteen to twenty percent with a bioavailability of forty to forty-five percent and a half-life of 2.5 to 3.
5 hours (Woo & Robinson, 2016). Its elimination of excretion is unchanged in the urine by twenty-five to thirty percent with the metabolism of thirty to thirty-five percent (Woo & Robinson, 2016). Drug Adverse Effects, Contraindications, Precautions, Drug to Drug Interactions, and Drug to Food Interactions, and Drug to Herb InteractionsMany of the drug interactions with this class of drugs are related to their metabolism by the CYPP450 enzyme system of the liver. There are fewer drug interactions with famotidine as compared to other drugs in this class. Examples of drug interactions with famotidine are ketoconazole which decreases the absorption. Therefore it is important to separate it for at least an hour and give ketoconazole first, and with food interactions, it may increase the bioavailability of famotidine (Woo & Robinson, 2016). Most of the adverse effects of H2RAs are mild and usually diminish as the individual takes it for a period.
Illustrations of side effects that can occur are constipation, diarrhea, nausea, trouble urinating, headaches, difficulty sleeping, drowsiness, or dizziness (Woo & Robinson, 2016). The more serious side effects that can occur with H2RAs are rare but can cause confusion, agitation, hallucinations, suicidal thoughts, vision changes, chest tightness, difficulty breathing, and irregular heartbeat (Woo & Robinson, 2016). Hence, it is essential that the patient contacts their provider right away or go to the hospital if experiencing any of these side effects. Although it is rare, the drug can cause hematological adverse reactions that include agranulocytosis, granulocytopenia, thrombocytopenia, and aplastic anemia. Therefore, these should be monitored (Woo & Robinson, 2016). The patient should also be aware and report black tarry stools because it may indicate GI bleeding. Some of the adverse effects may require dosage alteration or discontinuation of the drug.
Drug Administration Guidelines and MonitoringH2RA agents have the potential for hepatocellular damage. Consequently, the need for liver function testing is needed before initiating therapy and regularly throughout therapy. Renal impairment influences drug dosing for many drugs in this class. Thus renal function should also be assessed before treatment of therapy especially for the older population and to determine to dose for the patient (Woo & Robinson, 2016). The patient should do a follow-up evaluation in four weeks to determine the effectiveness of the medication treatment.Clinical Drug DosingH2RAs are available over-the-counter (OTC) and are the most used self-treatment and effective medication if used on-demand therapy for the relief of heartburn and GERD (Woo & Robinson, 2016). It is identified that H2RAs are not recommended for continuous treatment, but a dose given before bedtime and using as maintenance can help individuals on PPIs with nighttime reflux. Once-Daily dosing of this drug is not as effective in treating GERD conditions.
Famotidine dosage form can be given in a tablet of ten, twenty, and forty mg, powder for oral suspension of forty mg/five ml when reconstituted and injection form of ten mg/ml. The initial adult dosage is forty mg/d at bedtime or less than twenty mg two times a day (in morning and bedtime). The maintenance dose for adults is twenty mg at bedtime for up to eight weeks, in which most individuals heal in four weeks. Pepcid complete can also be given for the treatment of GERD, which comes in a chewable tablet with ten mg famotidine, 800 mg of calcium carbonate and 165 mg magnesium hydroxide. It is best to give the Pepcid complete ten mg with water an hour before a meal and can be used up to two times a day for two weeks for best results (Woo & Robinson, 2016). Patient EducationBased on the case study, Ms. Jones will need to follow the instructions as prescribed for the full course of therapy, even if feeling better for maximum relief.
The patient should not double dose, and if a dose was missed, it should be taken as soon as possible but not if it is close to the next dose time (Woo & Robinson, 2016). H2RA should be given with meals or immediately after and at bedtime for best effect. If medication is given daily, it is best to take it at bedtime for an effective result. If taking over-the-counter, the patient should not take the maximum dose continuously for more than two weeks without consulting with the provider due to diagnostic testing needed for a work up under these situations.
If the patient is taking other antacids or other drugs that interact with H2RA, it can produce interference with absorption. Hence the drug administrations should be separated for at least thirty minutes to an hour, and sucralfate should be taken two hours after the administration of H2RA (Woo & Robinson, 2016).ConclusionGERD is an enduring problem that may be prerequisite years of treatment to avert relapses. There is an instance that surgery may be desired if other alternatives are ineffective. However, health care providers assisting patients in their management of GERD should consider letting the patients’ symptoms determine the type of treatment required. GERD can range from mild to severe based on the severity and frequency of the patient’s symptoms.
In many cases, GERD can be treated with OTC medication such as antacids, H2RAs or proton pump inhibitors (PPI). As providers, it is important to make the appropriate decision that will lead to the safest and effective choice probable for the patient. The approach of a step-up or a step-down approach can be beneficial to help determine the appropriate method for the individual based on how persistent the symptoms are to ease their pain and discomfort.