What medication can be prescribed for heartburn in a patient with cholecystitis who declines Tums (calcium carbonate)?

From the Guidelines

For a patient with cholecystitis experiencing heartburn who doesn't want Tums, I recommend starting with a proton pump inhibitor (PPI) such as omeprazole (Prilosec) 20mg once daily before breakfast, as PPIs are more effective in treating esophageal GERD syndromes than other options 1. The current consensus supports treating patients with esophageal GERD syndromes with antisecretory drugs, and PPIs are more effective than H2 receptor antagonists (HRAs) or placebo 1.

• Key points to consider:
  • PPIs are the preferred initial treatment for patients with uncomplicated heartburn, due to their superior efficacy compared to HRAs and placebo 1.
  • The standard dose of PPIs is usually sufficient, as there is limited evidence to support the use of higher doses 1.
  • If symptoms persist despite once-daily PPI therapy, twice-daily dosing may be considered, although this is based on expert opinion rather than clinical trial data 1. It's essential to note that while PPIs can help manage heartburn symptoms, they don't treat the underlying cholecystitis, which typically requires separate management, such as antibiotics and possibly surgical intervention (cholecystectomy).
• Additional recommendations include:
  • Dietary modifications, such as avoiding fatty foods, caffeine, alcohol, and spicy foods, which can exacerbate both cholecystitis pain and acid reflux.
  • Eating small, frequent meals rather than large meals to reduce symptoms. The patient should be advised that persistent symptoms despite medication require follow-up evaluation.

From the FDA Drug Label

In a U. S. multi-center, double-blind, placebo-controlled study of 214 patients with frequent GERD symptoms, but no esophageal erosions by endoscopy, significantly greater relief of heartburn associated with GERD was observed with the administration of lansoprazole 15 mg once daily up to eight weeks than with placebo.

Table 17: Frequency of Heartburn Variable | Placebo (n=43) | Lansoprazole 15 mg (n=80) | Lansoprazole 30 mg (n=86) Median % of Days without Heartburn | Week 1: 10% | Week 1: 71% * | Week 1: 46% * | Week 4: 11% | Week 4: 81% * | Week 4: 76% * | Week 8: 13% | Week 8: 84% * | Week 8: 82% * % of Nights without Heartburn | Week 1: 17% | Week 1: 86% * | Week 1: 57% * | Week 4: 25% | Week 4: 89% * | Week 4: 73% * | Week 8: 36% | Week 8: 92% * | Week 8: 80% *

• (p < 0.01) vs placebo.

The patient can be prescribed lansoprazole 15 mg for the treatment of heartburn associated with GERD, as it has been shown to provide significant relief of heartburn symptoms compared to placebo 2.

From the Research

Patient Presentation

• The patient is presenting with cholecystitis and is requesting medication for heartburn, but does not want to take Tums.
• The patient's condition is likely causing discomfort and pain, and the request for heartburn medication suggests that the patient is experiencing symptoms of gastroesophageal reflux disease (GERD) in addition to cholecystitis.

Treatment of Cholecystitis

• According to the studies 3, 4, 5, 6, the gold standard treatment for acute cholecystitis is laparoscopic cholecystectomy, which should be performed within 72 hours of diagnosis.
• Early laparoscopic cholecystectomy is associated with improved patient outcomes, including fewer composite postoperative complications, a shorter length of hospital stay, and lower hospital costs 3.
• In patients who are not eligible for early laparoscopic cholecystectomy, percutaneous cholecystostomy tube placement may be an effective therapy, but it is associated with higher rates of postprocedural complications compared to laparoscopic cholecystectomy 3.

Treatment of GERD

• The study 7 suggests that combination therapy with proton-pump inhibitors (PPIs) and histamine(2) receptor antagonists may be effective in treating GERD, but the clinical significance of this finding is not clear.
• The study 7 also notes that the addition of histamine(2) receptor antagonists to twice-daily PPI therapy does not provide any further benefit above that derived from PPIs alone in patients with GERD.

Management of Patient's Request

• Given the patient's request for heartburn medication, a PPI or other medication for GERD may be considered, but the patient's primary condition of cholecystitis should be prioritized and treated accordingly.
• The patient's request to not take Tums suggests that alternative medications or treatments for GERD should be considered, but the patient's condition and treatment plan should be managed by a healthcare professional.