Acid suppression therapy

Acid-suppressing therapy is the mainstay of GERD treatment and should be considered for anyone not responding to lifestyle changes and patient-directed therapy after 2 weeks. 

Hour ambulatory pH monitoring may be the only way to objectively prove that symptoms are reflux-related in patients with atypical symptoms or non-erosive reflux disease. Ambulatory pH monitoring may also be useful in patients whose symptoms are not improving on adequate doses of acid-suppressing therapy. 

B. Standard dose acid-suppressing therapy Mild GERD can usually be treated effectively with... 

Rabeprazole 20 mg Palienls not responding to acid-suppressing therapy,... 

Antacids are an appropriate component of treating mild GERD, as they are clearly effective for immediate, symptomatic relief. They are often used concurrently with other acidsuppressing therapies. Patients who require frequent use of antacids for chronic symptoms should be treated with prescription acid-suppressing therapy. 

Record the frequency and severity of symptoms by interviewing the patient after 6 to 8 weeks of acid-suppressing therapy. Continued symptoms may indicate the need for long-term maintenance therapy. 

Gastric outlet obstruction occurs in approximately 2% of patients with PUD and is usually caused by ulcer-related inflammation or scar formation near the peripyloric region. Signs and symptoms of outlet obstruction include early satiety after meals, nausea, vomiting, abdominal pain, and weight loss. Ulcer healing with conventional acid-suppressive therapy is the primary treatment, but if this is unsuccessful then an endoscopic procedure (e.g., balloon dilation) is required. 

Determine the appropriate duration of therapy for acid-suppressive therapy. 

Evenepoel P, Claus D, Geypens B, Maes B, Hiele M, Rutgeerts P, et al Evidence for impaired assimilation and increased colonic fermentation of protein, related to gastric acid suppression therapy. Aliment Pharmacol Ther 1998 12 1011-1019. 

Antacids provide immediate, symptomatic relief for mild GERD and are often used concurrently with other acid-suppressing therapies. Patients... 

For typical symptoms, treat empirically with prescription-strength acid-suppression therapy. If symptoms recur, consider maintenance therapy (Ml). Note Most patients will require standard doses for MT. 

Promotility agents may be useful as adjuncts to acid suppression therapy in patients with a known motility defect (e.g., LES incompetence, decreased esophageal clearance, delayed gastric emptying). However, these agents are generally not as effective as acid suppression therapy and have undesirable side effects. 

The risk of infection rises with conditions that increase gastric pH and subsequent bacterial overgrowth, such as obstruction, hemorrhage, malignancy, or acid-suppression therapy (clean-contaminated). 

Gastroduodenal Enteric gram-negative bacilli, gram-positive cocci, oral anaerobes Cefazolin 1 g x 1 High-risk patients only (obstruction, hemorrhage, malignancy, acid suppression therapy, morbid obesity) IA... 

Pancrelipase is available in both non-enteric-coated and enteric-coated preparations. Pancrelipase enzymes are rapidly and permanently inactivated by gastric acids. Therefore, non-enteric-coated preparations (eg, Viokase tablets or powder) should be given concomitantly with acid suppression therapy (proton pump inhibitor or H2 antagonist) to reduce acid-mediated destruction within the stomach. Encapsulated formulations contain acid-resistant microspheres (Creon) or microtablets (Pancrease, Ultrase). Enteric-coated formulations are more commonly used because they do not require concomitant acid suppression therapy. 

Gradual increase of dose, change to a different formulation, or addition of acid suppression therapy may improve response. 

AMIODARONE H2 RECEPTOR BLOCKERS Cimetidine may t amiodarone levels Uncertain Monitor PR and BP at least weekly until stable. Warn patients to report symptoms of hypotension (lightheadedness, dizziness on standing, etc.). Consider alternative acid suppression therapy... 

DASATINIB H2 RECEPTOR BLOCKERS -FAMOTIDINE Possible 1 dasatinib levels Famotidine t metabolism of dasatinib Consider using alternative acid-suppression therapy... 

CODEINE CIMETIDINE Cimetidine may 1 efficacy of codeine Cimetidine inhibits CYP2D6-mediated conversion of codeine to its active metabolite. Ranitidine weakly inhibits CYP2D6 Watch for poor response to codeine. Consider using an alternative opioid or acid suppression therapy... 

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