What medication to administer as needed (prn) for gastroesophageal reflux disease (GERD) or heartburn in a hospital setting?

From the Guidelines

For heartburn in hospitalized patients, I recommend starting with proton pump inhibitors (PPIs) like pantoprazole 40mg IV/PO once daily or omeprazole 20-40mg PO once daily as first-line PRN therapy, as supported by the most recent guidelines 1. This approach is based on the latest evidence from the American Gastroenterological Association, which suggests that PPIs are more effective than H2 receptor antagonists (HRAs) in patients with esophageal GERD syndromes 1.

Key Considerations

• H2 receptor antagonists such as famotidine 20mg IV/PO twice daily are good alternatives, especially in patients at risk for C. difficile or pneumonia with PPIs.
• For immediate symptom relief, consider antacids like aluminum/magnesium hydroxide (Maalox) 30ml PO every 4-6 hours PRN or calcium carbonate (Tums) 1-2 tablets (500-1000mg) PO every 4-6 hours PRN.
• In patients with gastroparesis or delayed gastric emptying, adding a prokinetic agent like metoclopramide 10mg IV/PO before meals and at bedtime may help, as suggested by older guidelines 1.

Important Precautions

• Be cautious with PPIs in patients on clopidogrel, and avoid antacids within 2 hours of other oral medications as they may affect absorption.
• For patients with persistent symptoms, consider evaluating for other causes like stress ulcer prophylaxis needs, medication side effects, or underlying conditions requiring further workup, as recommended by the latest clinical practice update 1.

From the FDA Drug Label

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.

Table 1: Recommended Dosage Regimen of Omeprazole in Adults by Indication Indication Dosage of Omeprazole Treatment Duration Treatment of Symptomatic GERD 20 mg once daily Up to 4 weeks

For heartburn prn as a hospitalist, consider giving omeprazole 20 mg once daily for up to 4 weeks 2, 2.

• The dosage may vary based on the patient's condition and response to treatment.
• It is essential to follow the recommended dosage regimen and treatment duration to ensure effective management of heartburn symptoms.
• Omeprazole delayed-release capsules can be taken before meals, and antacids may be used concomitantly if needed 2.

From the Research

Treatment Options for Heartburn

• Antacids: Effective in providing quick relief for heartburn symptoms, with studies showing that antacids such as hydrotalcite 3 and aluminum/magnesium hydroxide 4 can increase esophageal pH and provide faster relief compared to placebo.
• Histamine-2 receptor antagonists (H2 RAs): Famotidine, an H2 RA, has been shown to be effective in relieving heartburn symptoms, with a delayed onset of action but a prolonged duration of effect compared to antacids 5, 6.
• Proton pump inhibitors (PPIs): While not directly studied in the provided evidence for PRN use, PPIs are generally recommended for frequent heartburn treatment, with a dose of 20 mg being optimal for empiric treatment 7.

Comparison of Treatment Options

• Antacids vs. H2 RAs: Antacids have a rapid onset of action but a shorter duration of effect, while H2 RAs have a delayed onset but a longer duration of effect 6.
• Antacids vs. Placebo: Antacids have been shown to be more effective than placebo in relieving heartburn symptoms 5, 3, 4.
• H2 RAs vs. Placebo: H2 RAs have been shown to be more effective than placebo in relieving heartburn symptoms 5.

Considerations for PRN Use

• Antacids can be used as needed for quick relief of heartburn symptoms, but may not provide long-term relief 3, 4.
• H2 RAs can be used as needed for relief of heartburn symptoms, but may have a delayed onset of action 5, 6.