What typical and atypical symptoms of GERD does the patient have? Which of the patient’s lifestyle and medications can make the GERD symptoms worse? Which of the patient’s medications decrease lower esophageal sphincter pressure? What is the drug of choice for the patient’s acid suppression therapy, and how long should the patient be treated?

Proton pump inhibitors are a class of novel drugs that are the most potent acid suppressors on the market today.  Since omeprazole’s introduction in 1990, they have been clinically proven to be better than H2RAs.  Over the past decade their use has been scrutinized because of several harmful disease associations.

• C. difficile infection: FDA’s analysis of over 28 studies revealed that patients taking PPIs were at a 1.4-2.75 times greater risk of developing an infection
• Fractures: FDA reviewed several studies and have concluded that PPIs in high doses, multiple daily doses, and/or continued therapy for longer than a year increase a person’s risk of osteoporosis related fracture
• Magnesium: PPIs may decrease magnesium level, which can lead to muscle spasms, arrhythmias, seizures, and fatigue.  This typically occurs after long-term administration of PPIs, usually longer than a year.  Treatment may require magnesium replacement and PPI discontinuation
• Dementia: Although several theories exist to possibly explain the mechanism, the association needs to be validated in large cohorts and tested in case-control studies. For now, it is probably safe to say a causal link is plausible.

Please discuss two of the three following options for this weeks post.

Option 1

What are some potential indications for the long term use of acid-suppressive therapy and given the above potential adverse events, what would your discussion entail for a patient, who through mutual decision making, is considering long term therapy with a PPI?

Option 2

H. pylori  infection causes gastritis, PUD, gastric cancer and mucosa-associated lymphoid tissue (MALT) lymphoma. Approximately 20% of infected individuals will develop PUD and less than 1% will develop gastric cancer. HP eradication markedly decreases ulcer recurrence. Assuming your patient tests positive for this organism, describe your therapeutic plan including possible medication options, patient and drug related factors used to make your selection, duration of therapy, monitoring, patient education and any potential follow up such as labs, testing or continued use for PPIs.

Option 3

A 64-year-old, Latin female patient was referred to your Clinic for gastroesophageal reflux disease (GERD) management after cardiac issues were ruled out. She has difficulty sleeping because of a burning feeling in chest at night which wakes her up. She notices more severe symptoms on the weekends. She is married and lives with her husband (a retired engineer) of 40 years. She and her husband have two sons, aged 37 and 35. She served in the Army for six years. She works as a legal assistant for law firm. She Smokes 5 cigarettes per day ( down from 1 ppd 2 years ago) and has 2-3 drinks on weekends, especially beer with dinner from the food trucks.