Question

CF is a 48-year-old man who presents for evaluation of heartburn. He denies current tobacco use but has a history of one ppd for 15 years. He consumes a glass of wine nightly, more on the weekends. He has a sedentary job.

He reports a burning feeling in his chest after eating. It is worse when he eats spicy foods or tomato sauce. He is sometimes awakened at night with these symptoms. He has tried over-the-counter antacids and histamine H2 receptor antagonists (H2RAs) with partial relief. He is on no medications regularly. His examination today is normal. An upper gastrointestinal (GI) x-ray series reveals gastroesophageal reflux.

1. Describe a rational drug choice for this patient. What counseling points about this medication do you give CF?

Answer 1

Ans) H2 receptor antagonists and H2 blocker therapy. H2 receptor antagonists are the first-line agents for patients with mild to moderate symptoms and grades I-II esophagitis. Options include ranitidine (Zantac), cimetidine(Tagamet), famotidine (Pepcid), and nizatidine(Axid).

• Medications that neutralize stomach acid. Antacids, such as Mylanta, Rolaids and Tums, may provide quick relief. But antacids alone won't heal an inflamed esophagus damaged by stomach acid. Overuse of some antacids can cause side effects, such as diarrhea or sometimes kidney problems.
• Medications to reduce acid production.These medications — known as H-2-receptor blockers — include cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR) and ranitidine (Zantac). H-2-receptor blockers don't act as quickly as antacids, but they provide longer relief and may decrease acid production from the stomach for up to 12 hours. Stronger versions are available by prescription.
• Medications that block acid production and heal the esophagus. These medications — known as proton pump inhibitors — are stronger acid blockers than H-2-receptor blockers and allow time for damaged esophageal tissue to heal. Over-the-counter proton pump inhibitors include lansoprazole (Prevacid 24 HR) and omeprazole (Prilosec OTC, Zegerid OTC).

Counseling points :

- Avoid lying down within three to four hours after a meal.

- Avoid medications that may potentiate GERD symptoms, including calcium channel blockers, beta agonists, alpha-adrenergic agonists, theophylline, nitrates, and some sedatives.

- Elevate the head of the bed 10 to 20 cm (4 to 8 inches).