Transcript Pharmaceutical guidelines of patients with pathology of digestive

Pharmaceutical guidelines of
patients with pathology of
digestive organs.
SYMPTOMATIC
TREATMENT OF
HEARTBURN
HEARTBURN
• typically begins with a burning sensation
that starts in the upper abdomen and
moves up into the chest, often making its
way to the back of the throat, and
sometimes up into the jaw, arms and back.
It usually feels worse when lying down or
bending forward.
• One in 10 Americans experiences
heartburn symptoms at least once a week.
Heartburn triggers
Healthy people:
• fat-laden or acidic foods,
• medications (aspirin),
• obesity,
• drinking alcohol,
• smoking,
• eating chocolate ,
• Pregnancy (Gaviscon effectively and rapidly treats heartburn
during pregnancy. Its use during pregnancy presents no known
significant safety concerns for mother or child)
• emotional turmoil,
• tension
• lying down
Heartburn causes
• Gastroesophageal Reflux (GERD) - stomach fluids
containing acid and digestive enzymes back up past the valve-like sphincter
that separates the stomach from the esophagus, causing pain.
• Gastrointestinal diseases:
Chronic gastritis (B), stomach ulcer disease,
chronic cholecyctitis
• diabetes,
• hiatal hernias,
• autoimmune disorders
Heartburn: An Inside Look
Food travels through the esophagus to the stomach. A valve-like ring of
muscle called the lower esophageal sphincter opens to let the food in.
Then it's supposed to close again to prevent stomach acids from sliding
up into the esophagus.
Heartburn: Faulty Valve
In some people, the sphincter between the stomach and esophagus
doesn't work as well as it should. This allows acid to seep into the
esophagus (called acid reflux), where it can cause pain and irritation.
Not everyone with acid reflux suffers from heartburn, and some people
with "heartburn" symptoms don't actually have acid reflux but may have
some other condition causing this pain.
Acid Reflux Symptoms
•
The hallmark of acid reflux is
heartburn -- a painful burning
sensation in the middle of the
chest. Heartburn typically
strikes after meals and can
last several hours. The
discomfort may be worse
after bending over or lying
down. Other symptoms of
severe acid reflux include a
sour-tasting fluid in the back
of the throat, difficulty
swallowing, or feeling that
food is stuck in the chest or
throat. A chronic cough or
asthma attacks can also be
caused by acid reflux. A
description of heartburn
symptoms is usually all that’s
needed to diagnose acid
reflux.
Heartburn: Who’s at Risk?
• Anyone can develop
heartburn, but certain
lifestyle factors affect how
well the sphincter works,
as well as the amount of
acid produced by the
stomach. People who are
overweight, eat large
meals, wear tight-fitting
clothes, or smoke tend to
be more vulnerable.
Is it GERD?
• Heartburn usually doesn't pose
a serious threat to health.
However, complications can
occur with severe, frequent,
and persistent acid reflux. If
someone have severe
heartburn or heartburn two or
more times a week, he may
have a condition called GERD
(gastroesophageal reflux
disease). Without treatment,
chronic GERD can cause
inflammation, ulcers, and
scarring. GERD can also lead
to changes in the cells lining
the esophagus. Known as
Barrett's esophagus (shown
here), compensation by
growing more cells like the
ones in the intestinal lining,
these changes raise the risk of
esophageal cancer.
Nighttime Heartburn
• Waking with a sore throat, cough, or
a bitter taste in mouth - It could be
nighttime acid reflux, and it could be
dangerous. In addition to disturbing
sleep, nighttime reflux increases the
risk of esophageal damage. That's
because lying down leaves stomach
acid in the esophagus longer. And
as we sleep we swallow less acidneutralizing saliva than when
awake.
Heartburn. Life-threatening
symptoms
• Accompanied by chest pain that feels like a
heart attack, persistent dry cough, vocal
modification, hoarseness, a sensation of
globus pharyngis (a lump at the back of the
throat) and otalgia (ear pain)
• Abdominal pain or difficulty swallowing,
• weight loss,
• fever or signs of bleeding, including vomiting
and black stools, which could indicate
bleeding from the esophagus into the
stomach
• Heartburn 3 days and more
• Heartburn connected with certain medicines
Managing Heartburn at Home
Heartburn treatment may include medications, home remedies, or diet
changes.
• Patient may be able to
manage mild heartburn
with a few changes to
daily routine. Start by
eating smaller meals.
Finish dinner at least
three to four hours before
bedtime and avoid latenight snacks.
Foods
• Some foods are known to
contribute to heartburn by
bringing additional acid
into the stomach or by
relaxing the lower
esophageal sphincter.
Should avoid tomatoes,
onions, garlic, chocolate,
peppermint, fatty foods,
and citrus fruits, including
oranges and grapefruit.
Beverages
• Certain beverages
can also bring on
heartburn. These
include coffee, tea,
sodas, alcohol,
tomato juice, and
orange juice.
Heartburn During Pregnancy
• More than half of all pregnant women report symptoms
of severe heartburn, especially during their second and
third trimesters.
• Changing hormone levels and increased abdominal
pressures during pregnancy increase the risk of acid
reflux and heartburn.
• Mild symptoms should be treated with lifestyle changes,
including eating several small meals a day instead of
three large ones, avoiding fried and spicy foods, and not
lying down after eating.
• If diet and lifestyle don't alleviate symptoms, pregnant
women should consult their doctor before taking any
medications.
Stop Smoking to Stop Heartburn
Smoking weakens the valve at the end of the esophagus, which can
lead to acid reflux and heartburn. And it increases the risk of various
gastrointestinal cancers. Smokers also have higher risks of developing
peptic ulcers and Crohn's disease than nonsmokers
Alcohol interferes with acid secretion, stomach muscles, and nutrient
absorption. Too many drinks can contribute to heartburn, diarrhea, liver
problems, esophageal and gastric cancer
Heartburn Remedies: Antacids
• For occasional heartburn, should
take something that works
immediately, like a liquid antacid. An
antacid neutralizes stomach acid.
This provides temporary relief from
heartburn, and is emptied from the
stomach quickly. It's important to
follow the directions carefully,
because the overuse of antacids can
cause serious side effects. And with
more prolonged heartburn symptom,
antacids may not help.
Antacids
• absorbed in
Sodium bicarbonate
Calcii carbonate
• nonabsorbed:
1st generation – (Al):
Phosphalugel
Compensan
2nd generation - (Al,
Mg):
Almagel, Maalox
3rd generation - (Al, Mg
+ alginate):
Gaviscon, Topalcan
Heartburn Remedies: Antacids
• They are also occasionally prescribed to help
relieve the pain of ulcers. Some antacids also
contain simethicone, an ingredient that helps
eliminate excess gas.
• Some antacids contain magnesium or sodium
bicarbonate, ingredients that may have a
laxative effect.
• Side effects include constipation, diarrhea,
white or pale bowel movements, and stomach
cramps. Serious side effects can occur with an
overdose or overuse of antacids.
ANTACIDS. GUIDELINES
• it is impossible to combine antacids with
de-nol and sucralfate (pharmacodynamic
incompatibility)
• all antacids are accepted only perorally - in
case of occurring of heartburn or in 1 hour
after-meal
• at the prolonged reception of antacids
there is propensity to the infections of
gastrointestinal way as a result of decline
of protective role of hydrochloric acid
ANTACIDS. GUIDELINES (cont’d)
• To the patients with hypertensive disease,
cardiac and kidney insufficiency, liver
cirrhosis antacids, containing sodium
bicarbonate, are contra-indicated. As a
result of chemical reaction with muriatic
acid they form chlorous sodium which is
well absorbed in and causes the delay of
water in an organism
• Absorbed antacids in large doses can
cause system metabolic reactions alkalosis
Heartburn Remedies: H2 Blockers
• Also available over-thecounter, H2 blockers work
differently than antacids.
Rather than zapping
acids after they appear,
these medications lower
the production of stomach
acid. This can help
prevent heartburn from
acid reflux if taken about
30 minutes before meals.
More powerful doses are
available in prescription
form.
H2 Blockers
• 1st generation (cimetidine)
• 2nd generation (ranitidine)
• 3rd generation (famotidine)
H2 blockers
• They can be taken at
bedtime to suppress
nighttime production of
acid. Available both overthe-counter and as
prescriptions, H2 blockers
help about half of
heartburn sufferers.
Brands include Axid,
Pepcid AC, Tagamet HB,
and Zantac 75
H2 blockers
• Possible serious side effects include confusion, chest
tightness, bleeding, sore throat, fever, irregular
heartbeat, weakness, and unusual fatigue. Other, less
serious side effects include headache, dizziness, and
diarrhea. These are usually temporary and will likely go
away on their own.
• When combined with lifestyle changes, these over-thecounter remedies relieve symptoms in about 25% of
heartburn sufferers. People who have more severe
heartburn symptoms that aren't relieved with these
medications or who have been using these drugs for
more than two weeks should contact their physician.
Acid Blockers: Proton Pump
Inhibitors
• Proton pump inhibitors,
available over-thecounter and by
prescription, are a class
of drugs that block the
production of stomach
acid. They are more
effective at decreasing
acid production than H2
blockers. Brands include
Aciphex, Nexium,
Prevacid, Prilosec,
Protonix, and Zegerid.
Promotility agents
• The drug Reglan speeds up the digestion
process and decreases the amount of
stomach acid that splashes back into the
esophagus.
Which Heartburn Medication to
Take?
• The heartburn treatment that's best for the
patient depends on many things. How often
does heartburn happen? How bad is it? Does
the patient want fast relief or prevention?
• Antacids offer fast relief for mild heartburn. H2
blockers can stop the burn before it starts, but
only if you know when to take them. Proton
pump inhibitors can tackle really stubborn
heartburn.
Hierarchy of efficacy for drug
treatments (most effective first)
• High dose proton pump inhibitors
• Standard dose proton pump inhibitors
• Half dose proton pump inhibitors
• Standard dose H2-receptor antagonists
• Antacids
• Long term safety and tolerability have
been extensively documented for H2
receptor antagonists and proton pump
inhibitors
• Cisapride has similar effectiveness to
standard dose H2 receptor antagonists but
is inferior to standard dose omeprazole.
There are two approaches to the
initial medical treatment
• Treatment can either start with the most effective
regimen and subsequently be stepped down or start with
the minimum intervention and be stepped up.
• The higher initial drug cost when beginning with the most
effective regimen is likely to be offset by rapid symptom
control, which is a substantial benefit to the patient and
reduces the need for repeated consultation. It is
recommend starting with the most effective treatment,
which is currently standard dose of a proton pump
inhibitor. This treatment is also the preferred choice for
empirical therapy.
• After the initial treatment, it is worth trying
a period without treatment because some
patients will not need further medical
intervention, at least for several months.
Patients in whom symptoms immediately
recur require longer term management.
Strategies for long term
management
• Most patients with gastro-oesophageal reflux
disease require long term management.
• The guiding principle for long term management
is to step down to the treatment that is least
costly but still effective in controlling symptoms,
• The rationale for this approach is minimisation
of cost, although relative drug costs will vary
across practice settings, and decreasing efficacy
does not always mean decreasing cost. Finding
the right level of management may take time in
some patients.
• For patients who require only intermittent
short courses of antisecretory therapy, it
may be more effective to give a proton
pump inhibitor at full dose than to titrate
treatment up from either half dose of
proton pump inhibitor or standard dose of
a H2 receptor antagonist.
Tegaserod, a 5-HT4-receptor
partial agonist, effectively treats
irritable bowel syndrome with
constipation.
• Tegaserod improved the esophageal pain
threshold to mechanical distention, and
distressing upper-GI symptoms in patients
with functional heartburn.