Pharmacology replies

Gastrointestinal Case Study

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 regular medications. His examination today is normal. An upper gastrointestinal (GI) X-ray series reveals gastroesophageal reflux.

1. What lifestyle modifications do you recommend for CF?

2. Describe a rational drug choice for this patient. Be specific regarding what factors you would consider. Include pharmacokinetic and dynamic considerations for the pharmacological choices made. Also consider interactions and side effects.

3. What counseling points about this medication do you give CF?

POST # 2 KAREN

This week’s scenario introduces CF, a 48-year-old male who presents today with a new diagnosis of gastroesophageal reflux disease (GERD). He is a current drinker, a former smoker, and has a sedentary job. He reports burning in his chest after eating, worse with spicy/high acid foods, and is sometimes awakened at night with these symptoms. CF has had some relief from over the counter antiacids and H2 receptor antagonists but takes no regular medications.  The first question to answer is what lifestyle modifications can CF make to improve his symptoms? Studies show that eliminating smoking, alcohol, caffeine, carbonated beverages, and chocolate can help minimize exacerbating factors (Patti, 2016). Other things CF can do include eating smaller meals, avoiding fluids with food, and avoiding food 3-4 hours before going to bed (West, 2019). More general lifestyle modifications include weight loss and elevating the head of the bed 30-40 degrees (West, 2019).  The next question asked is what is a rational drug choice for this patient? A Proton Pump Inhibitor (PPI) is the first lie drug of choice for GERD as they decrease acid secretion almost entirely and improve esophageal healing approximately 80% (Woo & Robinson, 2020), especially since over the counter choices have been only partially effective. Studies show that all types of PPI are equally effective at treating heartburn (Patti, 2016). I would begin this patient on an 8-week course of Lansoprazole at 15 mg daily (Woo & Robinson, 2020). Treatment for more than 8 weeks would be avoided if possible due to the risk of C-Diff infections (FDA 2017), fractures (FDA, 2017), and hypomagnesemia (FDA, 2017). The final question posed is what education we should be providing to patients on a PPI. Patient’s should be educated to take the medication exactly as prescribed, and if they miss a dose it should be taken when they remember unless it is almost time to take the next dose (Woo & Robinson, 2020). Patient’s should be advised to take the medication before a meal, preferably in the morning. Tablets should not be chewed or crushed, and patients should be advised it is safe to take a PPI with antacids (Woo & Robinson, 2020). The patient should also be given education on lifestyle modifications, and potential side effects of this medication.  Patti, M. G. (2016). An Evidence-Based Approach to the Treatment of Gastroesophageal Reflux Disease.  JAMA Surgery, 151(1), 73–78.  https://doi.org/10.1001/jamasurg.2015.4233 U.S. Food and Drug Administration (FDA). (2017). FDA Drug Safety Communication: Clostridium difficile  associated diarrhea can be associated with stomach acid drugs known as proton pump inhibitors  (PPIs).  https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication- clostridium-difficile-associated-diarrhea-can-be-associated-stomach U.S. Food and Drug Administration (FDA). (2017). FDA Drug Safety Communication: Possible increased  risk of fractures of the hip, wrist, and spine with the use of proton pump inhibitors.  https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/fda- drug-safety-communication-possible-increased-risk-fractures-hip-wrist-and-spine-use-proton- pump U.S. Food and Drug Administration (FDA). (2017). FDA Drug Safety Communication: Low magnesium  levels can be associated with long-term use of Proton Pump Inhibitor drugs (PPIs).  https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-low- magnesium-levels-can-be-associated-long-term-use-proton-pump West, B. (2019). Gastroesophageal Reflux Disease. Nutritional Perspectives: Journal of the Council on  Nutrition, 42(2), 12–13. Woo, T.M. & Robinson, M.V. (2020). Pharmacotherapeutics for advanced practice nurse prescribers (5th  ed.). F. A. Davis.