Heartburn_Dyspepsia Fall 2012 (1)

Cimetidine tagamet 200mg bid loss of libido nausea

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Cimetidine (Tagamet ® ) 200mg BID Loss of libido, nausea, gynecomastia, impotence CYP 3A4 inhibitor CYP 1A2 substrate Nizatidine (Axid ® ) 75mg BID Nausea, headache, leukopenia Ranitidine (Zantac ® ) 75-150mg BID Leukopenia, nausea, thrombocytopenia Famotidine (Pepcid ® ) 10-20mg BID Leukopenia, nausea, thrombocytopenia
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H 2 Antagonists Drug Interactions Cimetidine Renal dosing BID dosing more effective
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Administration May be used at onset of symptoms or 30 min – 1 hr before meal when heartburn is anticipated Lower doses Mild heartburn Higher doses Moderate heartburn Should not use more than twice daily (for self- treatment) Refer to health care provider if used for more than 2 wk Dose of all H 2 antagonists should be in patients with renal dysfunction
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Proton Pump Inhibitors (PPIs)
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Proton Pump Inhibitors (PPIs) Useful for moderate/severe, frequent heartburn Symptoms ≥ 2 days/week or for patients who do not respond to OTC H 2 antagonists MOA: Irreversibly innhibits hydrogen/potassium ATPase pump in parietal cell → decreased acid secretion Efficacy 90% Superior to H 2 antagonists Onset: 1-3 hours Duration: 12-24 hours
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Proton Pump Inhibitors (PPIs) Degrades in acidic environments Do not crush Take before meals to increase efficacy → inhibits only active pumps Vitamin B 12 deficiency No tachyphylaxis
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Proton Pump Inhibitors (PPIs) Drug Dose Side Effects Omeprazole (Prilosec OTC ® ) 20 mg daily Nausea, headache, diarrhea Lansoprazole (Prevacid 24 hour ® ) - available 11/09 15 mg daily
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Administration Should be taken once daily x 14 days May repeat course after 4 mo if symptoms recur Should be taken 30 min before breakfast Do not crush Tablet contains enteric-coated pellets Degrades in acidic environments efficacy Refer to health care provider if: Symptoms continue while taking PPI Symptoms persist > 2 wk Symptoms recur within 4 mo
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Combination Therapy Lifestyle therapy ± antacids + H 2 receptor antagonist Pepcid Complete ® (famotidine, calcium carbonate, and magnesium hydroxide) PPI Zegerid OTC ® Omeprazole: 20mg or 40mg Sodium bicarbonate: 1100mg
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Treatment Algorithm Berardi, RR et al. Figure 14-2
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Questions to Ask the Patient? What is the frequency, severity, and duration of the heartburn? What makes it worse and what makes it better? What risk factor(s) does the patient have that might contribute to his/her heartburn (any triggers, contributing factors, or medications that may exacerbate the symptoms)? Does he/she have any exclusion to self-treatment? What other medical disorders does the patient have and what prescription and OTC medications is he/she taking?
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