Case 016: Gastroesophageal Reflux Disease

PATIENT PRESENTATION

Chief Complaint

Heartburn and chest pain, especially when lying down

History of Present Illness

A 64-year-old, Latinx female patient was referred to the Pharmacy Clinic by her primary care provider for gastroesophageal reflux disease (GERD) management after cardiac issues were ruled out. The patient is a Veteran and receives care in the Veterans Affairs (VA) medical center, where clinical pharmacists have a global scope of practice to manage chronic conditions including GERD.

Link to EMR

Student Work-Up

TARGETED QUESTIONS

1. What typical and atypical symptoms of GERD does the patient have?

   Hint: See Clinical Presentation and Diagnosis in PPP

2. Which of the patient’s lifestyle and medications can make the GERD symptoms worse?

   Hint: See Clinical Presentation and Diagnosis and Table 18-1 in PPP

3. Which of the patient’s medications decrease lower esophageal sphincter pressure?

   Hint: See Table 18-1 in PPP

4. What is the drug of choice for the patient’s acid suppression therapy, and how long should the patient be treated?

   Hint: See Table 18-2, Figure 18-1, and Treatment in PPP

5. What risks and adverse effects of therapy would you discuss with the patient?

   Hint: See Treatment in PPP

FOLLOW-UP

How would you change the patient’s current acid suppression therapy? What are risks of PPI use in older adults?

Hint: See Table 18-2, Figure 18-1, Treatment in PPP

CASE SUMMARY

Global Perspective

Genetic variations with among patients may change PPI effectiveness because of an alteration in their ability to metabolize drugs through the cytochrome p-450 (CYP450) enzyme system primary through the cytochrome p-2c19. (CYP2C19). Drug interactions with omeprazole are associated more often with those who are considered “slow metabolizers.” Asian populations have a greater number of PPI rapid metabolizers compared to Caucasian populations. Rapid metabolizers may not receive optimal therapeutic effect from PPI therapy. There is not an established role in practice for using genetic testing to alter PPI dosing related to these genetic variations. PPIs may differ in the extent of drug – drug interaction related to the CYP450 enzyme system. For example, esomeprazole is metabolized more readily by CYP3A4 enzymes and may be affected less by the patient’s genotype. Therefore, patients on PPI therapy should be monitored routinely for drug interactions and associated drug-related problems.