Diagnosis
H&P:
–GerdQ Questionnaire: Total score = ___ points = ___ percent likelihood of GERD.
-Assess for red flags or alarming symptoms.
-Assess for indications for EGD.
–H. Pylori testing is not routinely recommended in patients with GERD.
-DDx / Etiology:
Treatment
–Lifestyle modifications.
-Pharmacotherapy options reviewed. Step-up and step-down tx approaches discussed.
-Discussed compliance and when to take medications. Take PPIs 30 to 60 minutes before meals.
-Will send the patient for EGD if typical GERD symptoms persist despite a therapeutic trial of PPIs BID for 4 to 8 weeks.
-Patient counseled that PPI’s may take up to 4 days to work. As such, they aren’t good for acute or prn treatment.
-Patient counseled about the diagnosis, alternative treatment options, risks, and benefits.
-Patient counseled that PPI therapy has been associated with an increased risk of hip fracture, osteoporosis, hypomagnesemia, community-acquired pneumonia, vitamin B12 deficiency, and Clostridium difficile infection.” Protonix also associated with thrombocytopenia.
-Recommend antacids e.g. calcium carbonate (Tums) for breakthrough symptoms since it is fast acting.
-No indication for GI referral at this time.
-Indications for surgery discussed.
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Important GERD Links and Pearls
- Long-term effects of PPI use.
- GI Cocktail.
- PPIs, H2-Blockers, and Antacids.
- Basal and Acid Stimulated Acid Secretion.
H2 Receptor blockers: Onset in 1 hour; Last about 9 hours. Are 1st line for mild or intermittent GERD symptoms. E.g. Ranitidine 150 mg PO BID. Can try ranitidine for 8 weeks and if it doesn’ work, then step up to PPIs which are more effective. Note that they may interact with some drugs like Phenytoin and Warfarin.
**If a patient is having GERD very infrequently, maybe only once or twice a week, H2 blocker used prn may be a good idea. My program director does this.
**When using PPIs for reflux esophagitis, start with QD treatment. If no response, response, will go from QD to BID dosing.
**GERD is divided into two: Erosive esophagitis and non-erosive GERD.
***PPIs are always the initial treatment of choice in patients with erosive esophagitis seen on EGD.
***For reflux esophagitis, you can do step-up (start with H2-blocker then go to PPI) or step-down (start with PPI then go down to H2 blocker). There are some studies that show that it may be cost-effective to start and stay on PPI for reflux esophagitis.
“PPIs are more effective for relieving GERD symptoms than H2 antagonists and may be more cost-effective than step therapy. An RCT supported the cost- and clinical effectiveness of starting with a PPI rather than step therapy with an H2 antagonist when treating reflux esophagitis.” AAFP 2015
References
Great AAFP articles:
Ann Intern Med. 2012;157:808-816 (http://annals.org/aim/article/1470281/upper-endoscopy-gastroesophageal-reflux-disease-best-practice-advice-from-clinical)
Am Fam Physician. 2015 May 15;91(10):692-697. (http://www.aafp.org/afp/2015/0515/p692.html)
http://www.aafp.org/afp/2015/1015/p705.html
http://www.aafp.org/afp/2010/0515/p1278.html
Am Fam Physician. 2003 Oct 1;68(7):1311-1319. (http://www.aafp.org/afp/2003/1001/p1311.html)
https://www.ncbi.nlm.nih.gov/pubmed/24512269