Question

A 47-year-old male has been diagnosed with moderate to severe gastroesophageal reflux disease. He reports increase in episodes when lying down and after meals. Other symptoms and information include frequent cough, sore throat and hoarse voice, smoking, high fat diet, and obesity. You may assume that the diagnosis is correct. Referring to the directions for completing the case studies and the grading rubric create a pharmacologic treatment plan for your patient What drug or drugs will you prescribe; provide the rationale Provide the pharmacological data pertinent to each drug included (dose, route, dose interval) How will you evaluate the efficacy of your treatment? laboratory monitoring, clinical assessment for therapeutic, adverse and toxic effects, drug dose/route changes as needed,

What about future contingencies & revisions; consideration of needs for follow-up, medication monitoring, lifestyle modifications & patient teaching.

Are your decisions validated by supporting literature?
                        

Answer 1

GERD is a disease condition in which relaxed cardiac sphincter will lead to reflux of food back into the esophagus from the stomach. The main symptom identified is pyrosis.

According to the grading rubric,a tool that is used to check the effectiveness of an intervention. Here we have to create a pharmacological treatment plan.

• Antacids: for quick relief of symptoms .It will neutralise the acid secretion inside the stomach which reduces the heart burn .It should be taken after meals. The drugs we can include here is mylanta,rolaids and tums. Mylanta ( amphogel-aluminium hydroxide), route of administration- oral [liquid form 10-20ml, tablet in chewable form 2 to 4 tablets]. We should advice the patient not to take more than 12 tablets a day. These drugs can cause nausea, vomiting , diarrhea, and stomach cramps. Rolaids is a calcium based antacid. It is available in both oral suspension 5ml PO PRN basis . It should not exceed 7g of calcium carbonate per day and in chewable form 110mg orally 2-4 tabs a day in PRN basis.Adversw effects include anorexia, constipation, Acid rebound etc
• H2 receptor antagonist to reduce the acid production especially HCl production in the gastric cavity. The drugs we can add here are cimetidine and famotidine. This drugs is best to take with meals. Cimetidine 800mg orally available. It should be taken twice a day at bedtime or during meals for GERD for 12 weeks.The side effects include dizziness, drowsiness and diarrhea
• Proton pump inhibitors to heal the lesion of esophagus due to the burns caused in reflux and also to block the acid production.the drugs we can provide include pantoprazole and omeprazole. PPI are best taken before meals.Pantaprazole 40 mg orally once a day before food for 8 weeks or 50 mg IV infusion once a day over at least 2 minutes or over 15 minutes for a duration of 7 to 10 days.The main adverse effects include headache, nasopharyngitis, abdominal discomfort, depression jaundice,pruritus, myalgia, hypertension and vitamin B12 deficiency .

Based on these drug adverse effects we can change the dose or alternative drug . For example aluminium hydroxide can cause constipation , so we can get the order from physician for magnesium hydroxide to get relief from that. Then while taking these drug lab investigation to be done includes NaHCO3, MG(OH)2,Al(OH)3, CaCCO3 to confirm alkalosis, toxicity and acid rebound. Liver function test is done while the intake of PPI.

The main lifestyle and teaching that is needed for a patient with GERD includes ,

1. Maintain a healthy weight
2. Stop smoking
3. Elevate the head of your bed after meals.Dont lie down immediately after meals
4. Eat food slowly and take small and frequent diet
5. Avoid carbonated beverages
6. Avoid tight fitting clothes.
7. Avoid high fat diet or greasy food items.

There are so many review of literature which shows the effectiveness of drug and life style modification which will cure this GERD.A research finding is given below;

A 20-year follow-up of 2306 patients who received symptom-driven antireflux treatment indicated that only one patient with a normal baseline mucosa developed esophageal stricture requiring dilation (0.08%), but that 18 patients with an erosive baseline mucosa were affected (1.9%). The overall incidence of stricture in patients with GERD was <1/1,000 per year (Sontag et al 2006).

The optimal treatment of GERD is vital for a number of reasons. GERD is a chronic, relapsing disease that can progress to major complications; affected patients have significantly poorer health-related quality of life than the general population, with impairment being proportional to the frequency and severity of symptoms; and as GERD requires continued therapy to prevent relapse and complications, most patients with erosive esophagitis require long-term acid suppressive treatment. Thus GERD results in a significant cost burden.

The effective treatment of GERD provides symptom resolution and high rates of remission in erosive esophagitis, lowers the incidence of GERD complications, improves health-related quality of life and reduces the cost of this disease. PPIs are accepted as the most effective treatment for GERD and are the mainstay of initial GERD management, providing more rapid symptom control and better healing of erosive esophagitis than H2-receptor antagonists and antacids. PPIs are also the preferred agents for maintenance therapy in patients with healed erosive esophagitis (Lauritsen et al 2003). As few differences in safety or efficacy have been reported between the available PPIs, the decision to select one PPI over another is most likely to be based on the agents’ acquisition costs, formulations, Food and Drug Administration-labeled indications, and overall safety profiles (Welage and Berardi 2000).

The data reviewed here show that oral pantoprazole is a safe, well tolerated and effective initial and maintenance treatment for patients with nonerosive GERD or erosive esophagitis. Oral pantoprazole has greater efficacy than that of H2-receptor antagonists and generally has similar efficacy to other PPIs for the initial and maintenance treatment of GERD. In addition, oral pantoprazole has been shown to improve the quality of life of patients with GERD and is associated with high levels of patient satisfaction with therapy. GERD appears to be more common and more severe in the elderly. Furthermore, as elderly are taking multiple medications at the same time, or drugs with a narrow therapeutic window, drug interactions may be of particular importance in those patients. Pantoprazole has also shown to be an effective and safe treatment for this at-risk population.