GERD

Question 1

Complications of GERD?

Answer 1

• ulcers
• strictures
• throat problems (due to acid reflux i.e. sore throat, hoarse voice)
• Barrett’s esophagus
• esophageal adenocarcinoma
• pulmonary disease

Question 2

Etiology of GERD?

Answer 2

• transient lower esophageal sphincter (LES) relaxation
• hypotensive LES
• anatomic disruption of gastro-esophageal junction a/w hiatal hernia (stomach pushes up thru a hole in diaphragm muscle e.g. coughing)

Question 3

Risk factors of GERD? (7)

Answer 3

• elderly
• pregnancy (estrogen & progesterone increase esophageal sphincter muscle relaxation)
• obesity
• comorbidities (IBS, PUD, anxiety, depression, sleep disorders)
• medications
• diet
• cigarette smoking

Question 4

Medications that affect LES pressure? (8)

Answer 4

• anticholinergics: atropine, hyoscine butylbromide, oxybutynin
• beta adrenergic agonists: salbutamol etc
• alpha adrenergic antagonist: prazosin, terazosin
• CCB: non-DHP, nifedipine
• opioids
• progesterone
• caffeine, theophylline
• TCA: amitriptyline

Question 5

Difference between GERD & PUD?

Answer 5

Acidic taste in mouth

Question 6

Extra-esophageal symptoms of GERD? (4)

Answer 6

• cough, wheezing, SOB
• sore throat, hoarseness
• teeth erosion
• otitis media

Question 7

Pharm options for GERD? and forensic classification

Answer 7

• antacids, alginates (mostly GSL)
• H2RA (POM with exemption)
• PPI (POM / POM with exemption)

Question 8

When to take H2RA / PPI?

Answer 8

30-60 minutes before meals

Question 9

Which is superior: PPI or H2RA?

Answer 9

PPI

Question 10

What should patients take if they have predictable or unpredictable symptoms?

Answer 10

• predictable: H2RA, PPI
• unpredictable: antacids, alginates PRN

Question 11

Examples of antacids?

Answer 11

• aluminium hydroxide
• magnesium hydroxide
• calcium carbonate
• sodium bicarbonate

Question 12

Examples of alginates?

Answer 12

• Gaviscon (sodium alginate, calcium carbonate, sodium bicarbonate)

Question 13

Requirements to purchase famotidine?

Answer 13

• max daily dose: 20mg
• max supply: 2 weeks

Question 14

Requirements to purchase omeprazole, pantoprazole and esomeprazole? (except zenpro 20 and omesec 20)

Answer 14

• min age: 18
• max daily dose: 20mg
• max supply: 2 weeks

Question 15

Which PPI is not P+?

Answer 15

Lansoprazole

Question 16

For antacids, are solid or liquid formulations faster?

Answer 16

Liquid

Question 17

Potency of antacids?

Answer 17

Al < Mg < Na < Ca

Question 18

When to administer antacids & alginates?

Answer 18

after food, before bedtime

Question 19

For alginates, what should patient do after taking?

Answer 19

remain upright and avoid food & drinks for ≥30min

Question 20

What drugs require spacing apart from GERD meds and why?

Answer 20

• iron
• enteric coated meds
  etc
  because they need acidic env to be absorbed

Question 21

What are short term and long term use of PPI a/w?

Answer 21

short term: CAP
long term: vit B12 deficiency, C diff, hypo Mg, increased risk of fractures

Question 22

PPIs are CYP___ inhibitors/inducers?

Answer 22

CYP2C19 inhibitors

Question 23

What is suitable for pregnancy for GERD?

Answer 23

• antacids (caution sodium: risk of metabolic alkalosis, fluid overload in mum & kid)
• H2RAs
• PPIs (probably)

Question 24

What is NOT suitable for pregnancy? Why?

Answer 24

magnesium trisillicate (risk of nephrolithiasis, hypotonia, resp distress in fetus)

Question 25

What is suitable for lactation?

Answer 25

- antacids - H2RA

Question 26

What is not suitable for lactation and why?

Answer 26

PPI, secreted into breastmilk

Question 27

Place of treatment for GERD in pregnancy?

Answer 27

antacid > H2RA > PPI

Question 28

Most suitable option for GERD in elderly? Why not the rest?

Answer 28

PPI H2RA a/w CNS effects

Question 29

Minimum age for using antacids? - magnesium carbonate aromatic mixture - eno powder - Rennie tablet

Answer 29

- magnesium carboante aromatic mixture: 1y - eno powder: 2y - Rennie tablet: 6y

Question 30

What CrCl to avoid antacid? Which med need renal dose adjustment?

Answer 30

<30 H2RA need dose adjust, PPI no need