What is the appropriate management for a 27-year-old female with a history of asthma, borderline personality disorder, depression, epilepsy, diabetes, gastroesophageal reflux disease (GERD), and chronic sinusitis, presenting with a flare-up of acid reflux and vomiting for 48 hours, despite taking Pepcid (Famotidine) as prescribed, and with significant allergies limiting antiemetic options?

From the Guidelines

This patient should be provided with a work excuse due to her acute vomiting episode related to GERD flare-up. I recommend continuing her prescribed Pepcid (famotidine) and adding a proton pump inhibitor such as omeprazole 20mg once daily for 14 days to better control her acid reflux symptoms, as suggested by the most recent guidelines 1. She should maintain a liquid diet initially, gradually advancing to small, frequent bland meals as tolerated.

• Elevating the head of her bed by 6-8 inches and avoiding meals within 3 hours of bedtime will help reduce nighttime reflux, as recommended by the American Gastroenterological Association 1.
• Given her multiple comorbidities including asthma, epilepsy, and diabetes, close monitoring of her hydration status is important.
• Her chronic sinusitis with postnasal drainage may be exacerbating her GERD symptoms through increased swallowing of mucus, and treatment of GERD may benefit patients with asthma and complain of frequent heartburn or pyrosis, particularly those who have frequent nighttime asthma symptoms 1.
• The upcoming ENT follow-up and sinus CT are appropriate for addressing this contributing factor.
• Her extensive allergy list limiting antiemetic options makes controlling the primary cause of vomiting (acid reflux) even more critical. She should return for reassessment if unable to tolerate oral intake for more than 24 hours or if she develops new concerning symptoms like chest pain, severe abdominal pain, or bloody emesis. The use of upper endoscopy in patients with GERD symptoms and no alarm symptoms is not generally recommended, but may be considered if empirical acid-suppressive therapy is unsuccessful 1.

From the FDA Drug Label

1.4 Treatment of Symptomatic Gastroesophageal Reflux Disease (GERD) Omeprazole delayed-release capsules are indicated for the treatment of heartburn and other symptoms associated with GERD for up to 4 weeks in patients 2 years of age and older.

2.1 Recommended Adult Dosage Regimen by Indication Table 1 shows the recommended dosage of omeprazole in adult patients by indication Indication Dosage of Omeprazole Treatment of Symptomatic GERD 20 mg once daily Up to 4 weeks

The patient's symptoms of acid reflux and vomiting are consistent with GERD. The recommended dosage of omeprazole for the treatment of symptomatic GERD is 20 mg once daily for up to 4 weeks 2.

• The patient has already been taking Pepcid as prescribed by her PCP, but she is still experiencing symptoms.
• Omeprazole may be considered as an alternative treatment option for her GERD symptoms.
• However, given the patient's complex medical history and significant allergy list, it is essential to exercise caution and consider potential interactions or contraindications before initiating omeprazole therapy 2.

From the Research

Patient Presentation

The patient is a 27-year-old female with a significant past medical history, including asthma, borderline personality disorder, depression, epilepsy, diabetes, GERD, and chronic sinusitis. She presents with a flare-up of her acid reflux, vomiting for the past 48 hours, and postnasal drainage.

Current Treatment

The patient has been taking Pepcid as prescribed by her PCP and is awaiting a CT of her sinuses due to chronic sinusitis. She is tolerating oral liquids but has a significant allergy list and is unable to take many antiemetics.

Treatment Options for GERD

• Proton pump inhibitors (PPIs) are effective in treating GERD, with studies showing that they can heal reflux esophagitis and reduce symptoms 3, 4.
• Esomeprazole is a PPI that has been shown to be effective in treating GERD, with once-daily oral doses demonstrating greater antisecretory activity than other PPIs 4, 5.
• Combination therapy with PPIs and histamine(2) receptor antagonists has been evaluated, but the clinical significance of this approach is not clear, and further investigation is needed to determine optimal therapy in patients refractory to standard doses of PPIs 6.

Management of PPI-Refractory GERD Symptoms

• Up to 40% of patients who take PPIs for GERD complain of persistent GERD symptoms, and there is no clear consensus on the type, dosing, and duration of PPI therapy required to establish a diagnosis of PPI-refractory GERD symptoms 7.
• Patients who do not respond to PPIs may require further evaluation and management, including consideration of alternative diagnoses and treatment options.

Work Excuse

The patient is requesting a work excuse, which may be necessary given her current symptoms and treatment regimen. However, the decision to grant a work excuse should be based on the patient's individual circumstances and medical needs.