College of Pharmacy
Case 1:
GERD symptoms: heartburn (classic symptom), belching, nausea, dysphagia (alarm symptom unless otherwise explained, ask patient if he has had unintended weight loss or other alarm symptoms), hoarseness. While not specifically described here, some GERD symptoms (e.g., cough, SOB) mimic those of COPD which this patient has and chest pain is sometimes a symptom of GERD, as well as cardiac ischemia (patient has CAD).
With presence of an alarm symptom, ask patient whether this has been discussed/assessed by his physician. If not, recommend he contact his physician immediately for evaluation of possible GERD and potentially serious complications of this.
Belching and nausea may be related to gastroparesis that can cause/worsen GERD (patient has DM, increasing risk for gastroparesis).
Provoking factors for GERD: Smoking, alcohol, ASA, KCl, isosorbide mononitrate, inhaled form of anticholinergic unlikely to cause GERD (reassess need/benefit). Assure minimum effective doses. Essential meds with no safer alternatives, despite worsening GERD, may need to be continued at minimum effective dose depending on how critical the need (plus GERD therapy maximized for control).
Recommend: See MD if warranted (per above), If GERD diagnosed, PPI (equivalent of omeprazole 20 mg 15-30 min before breakfast) will be most effective if GERD (suggested by dysphagia, a GERD complication). Ranitidine acceptable at dose of 150 mg BID if NERD or possibly grade 1 or 2 esophagitis (although, most now advise PPI if any grade esophagitis). If ranitidine ineffective at 150 mg BID (which is higher than current dose of 150 mg/d), PPI should be started. H2RAs less effective in relieving symptoms and healing esophagitis than PPIs. Monitor GERD symptoms and complications such as alarm sx, anemia. For GERD or NERD: modify lifestyle factors (see case 2 that follows for details of lifestyle changes).