Pharmacology - Chapter Twenty-Six

A patient who has GERD has been taking a PPI for 2 months and reports a slight decrease in symptoms. The next response of the primary care NP is to: a- add a histamine-2-receptor agonist. b- increase the dose of the PPI. c- change to long-term, low-dose PPI therapy. d- refer the patient to an endocrinologist for endoscopy and further management.

a- add a histamine-2-receptor agonist. If treatment with a PPI is inadequate by 2 months, histamine-2-receptor agonist therapy is indicated. Increasing the dose is not indicated. Long-term, lower dose therapy is used for recurrences of symptoms on a limited basis. When symptoms fail to resolve with pharmacologic treatments, patients should be referred to an endocrinologist.

An 80-year-old patient asks a primary care NP about OTC antacids for occasional heartburn. The NP notes that the patient has a normal complete blood count and normal electrolytes and a slight elevation in creatinine levels. The NP should recommend: a- calcium carbonate (Tums). b- aluminum hydroxide (Amphojel). c- sodium bicarbonate (Alka-Seltzer). d- magnesium hydroxide (Milk of Magnesia).

a- calcium carbonate (Tums). Elderly patients with renal failure should not take antacids containing magnesium because of the risk of hypermagnesemia. Sodium-containing antacids may cause fluid retention in elderly patients. Aluminum hydroxide is not as effective as calcium carbonate.

A patient who has GERD with erosive esophagitis has been taking a PPI for 4 weeks and reports a decrease in symptoms. The patient asks the primary care NP if the medication may be discontinued. The NP should tell the patient that: a- the dose may be decreased for long-term therapy. b- antireflux surgery must be done before the PPI can be discontinued. c- the condition may eventually be cured, but therapy must continue for years. d- once the symptoms have cleared completely, the medication may be discontinued.

a- the dose may be decreased for long-term therapy. Once PPIs have proven clinically effective for treatment of patients with esophagitis, therapy should be continued long-term and titrated down to the lowest effective dose based on symptom control. PPI therapy is considered safer than surgery and should be tried first before surgery is performed. GERD is a lifelong syndrome and is not curable.

A patient in the clinic reports heartburn 30 minutes after meals, a feeling of fullness, frequent belching, and a constant sour taste. The patient has a normal weight and reports having a high-stress job. The primary care NP should recommend: a- antacid therapy as needed. b- changes in diet to avoid acidic foods. c- daily treatment with a PPI. d- consultation with a gastroenterologist for endoscopy.

c- daily treatment with a PPI. This patient has symptoms of GERD. PPIs are first-line medications for treating GERD and may be started empirically. Antacids are not first-line medications. Changes in diet are not recommended as treatment but may help with symptoms. Patients with symptoms unrelieved by PPIs should be referred for possible endoscopy.

A patient who has gastroesophageal reflux disease (GERD) undergoes an endoscopy, which shows a hiatal hernia. The patient is mildly obese. The patient asks the primary care nurse practitioner (NP) about treatment options. The NP should tell this patient that: a- a fundoplication will be necessary to correct the cause of GERD. b- over-the-counter (OTC) antacids can be effective and should be tried first. c- elevation of the head of the bed at night can relieve most symptoms. d- a combination of lifestyle changes, medications, and surgery may be necessary.

d- a combination of lifestyle changes, medications, and surgery may be necessary. People with GERD often have hiatal hernia, but this is not the cause of GERD. The approach to treatment of GERD may include lifestyle changes, medications, and surgery. OTC antacids are sometimes used but are rarely used as first-line treatment.

A patient undergoes endoscopy, and a diagnosis of erosive esophagitis is made. The patient does not have health insurance and asks the primary care NP about using OTC antacids such as Tums. The NP should tell the patient that Tums: a- can help to heal erosions in esophageal tissue. b- do not help reduce symptoms of erosive esophagitis. c- neutralize stomach acid as well as proton pump inhibitors (PPIs). d- help reduce symptoms in conjunction with PPIs.

d- help reduce symptoms in conjunction with PPIs. Antacids reduce symptoms but do not have a significant effect on healing of erosions or esophagitis. If the patient has severe symptoms, has found treatment for milder symptoms to be ineffective, or has experienced erosion that is documented by endoscopy, he or she should be started on a PPI.

A patient is taking a low-dose PPI for long-term management of GERD and reports taking sodium bicarbonate (Alka-Seltzer) to help with occasional heartburn. The primary care NP should tell the patient to: a- change to aluminum hydroxide (Amphojel). b- use magnesium hydroxide (Milk of Magnesia) instead. c- continue using sodium bicarbonate (Alka-Seltzer) as needed. d- take calcium carbonate (Tums) instead of sodium bicarbonate (Alka-Seltzer).

d- take calcium carbonate (Tums) instead of sodium bicarbonate (Alka-Seltzer). Sodium bicarbonate is not suitable for long-term use because of side effects. Calcium carbonate requires monitoring when used long-term but has the highest acid-neutralizing capacity. Antacids containing aluminum and magnesium can cause electrolyte imbalances.