Pharmacotherapy Case Study: Gastroesophageal Reflux Disease (GERD) By: Dr. Nehad Ahmed

 

Pharmacotherapy Case Study: Gastroesophageal Reflux Disease (GERD) By: Dr. Nehad Ahmed

 

Patient Profile:

·        Age: 45 years

·        Gender: Male

·        Medical History: Hypertension, managed with amlodipine

·        Lifestyle Factors: Sedentary lifestyle, high-fat diet, occasional alcohol consumption

Subjective Data:

·        Chief Complaint: Persistent heartburn and regurgitation for the past three months.

·        Symptom Description:

o   Heartburn occurring after meals, especially post-dinner.

o   Regurgitation of sour liquid into the mouth, particularly when lying down.

o   Occasional chest discomfort, not radiating.

·        Lifestyle Factors:

o   Diet rich in spicy and fatty foods.

o   Consumes caffeinated beverages and alcohol regularly.

o   Reports high levels of stress at work.

Objective Data:

·        Physical Examination:

o   Vital signs: BP 130/85 mmHg, HR 78 bpm, RR 16/min, Temp 98.6°F.

o   Abdominal examination: No tenderness or masses.

o   No signs of anemia or jaundice.

 

·        Laboratory Tests:

o   Complete blood count: Normal.

o   Liver function tests: Normal.

o   Helicobacter pylori test: Negative.

·        Diagnostic Imaging:

o   Upper endoscopy: Mild esophagitis observed.

o   24-hour pH monitoring: Positive for acid reflux episodes.

Assessment:

The patient presents with classic symptoms of GERD, including heartburn and regurgitation, exacerbated by dietary and lifestyle factors. Objective findings, such as mild esophagitis on endoscopy and positive pH monitoring, confirm the diagnosis.

Pharmacotherapy Plan:

1.     Proton Pump Inhibitors (PPIs):

o   Medication: Omeprazole 20 mg daily before breakfast.

o   Rationale: PPIs are the first-line treatment for GERD, effectively reducing gastric acid production and promoting esophageal healing.

2.     H2 Receptor Antagonists (H2RAs):

o   Medication: Ranitidine 150 mg at bedtime.

o   Rationale: H2RAs can be used as adjunctive therapy, especially for nocturnal symptoms.

3.     Antacids:

o   Medication: Calcium carbonate as needed for breakthrough symptoms.

o   Rationale: Provides rapid relief of heartburn by neutralizing stomach acid.

Lifestyle Modifications:

·        Dietary Changes:

o   Avoid trigger foods such as spicy, fatty, and acidic items.

o   Limit caffeine and alcohol intake.

 

·        Behavioral Modifications:

o   Eat smaller, more frequent meals.

o   Avoid lying down immediately after eating.

o   Elevate the head of the bed to reduce nocturnal reflux.

·        Stress Management:

o   Engage in regular physical activity.

o   Practice relaxation techniques to manage stress.

Monitoring and Follow-Up:

·        Short-Term:

o   Assess symptom relief after 4 weeks of therapy.

o   Evaluate for potential side effects of medications.

·        Long-Term:

o   Monitor for complications such as esophageal strictures or Barrett's esophagus.

o   Consider maintenance therapy with PPIs if symptoms persist.

Patient Education:

·        Educate the patient on the importance of adherence to prescribed medications and lifestyle modifications.

·        Discuss potential side effects of PPIs, including vitamin B12 deficiency and bone fractures with long-term use.

·        Encourage regular follow-up appointments to monitor treatment efficacy and adjust therapy as needed.