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This Continuing Education Activity is jointly provided by Dannemiller and Pharmacy Times Continuing Education.

Treating Acute Strains and Sprains in the Convenient Care Clinic

It is that time of year again, when health care providers see an increase in patient volume because no one has time to be sick. Ah yes, the common

cold that can keep children out of school, athletes out of games, adults out of work, and elderly individuals out of commission and basically disrupt life as we know it. There are more than 100 strains of rhinoviruses that cause the majority of colds.

The common cold typically starts with a sore throat, turns into nasal congestion, a runny nose, and sneezing, and then finishes off with a nagging cough that can last up to 2 weeks. Who has time for this?

The first step in educating patients: Tell them to try not to catch the common cold in the first place. They should be aware that hands carry cold viruses and those viruses can stay on skin surfaces for up to 2 hours. People need to cough into the bend of their elbows and not their hands. And if they do touch their hands, they should not touch their eyes, noses, or mouths. In addition, they should wash their hands before they eat, as cold viruses can live on surfaces such as doorknobs, faucet handles, phones, armrests, and tray tables on planes. And those who happen to stand next to a person with a cold virus who coughs or sneezes a droplet into their eyes, nose, or mouth likely won’t be feeling well within the next 48 to 72 hours.

Treatment is all about controlling the symptoms, and an antibiotic isn’t going to help. Let’s look at this from the patient’s perspective. They head to the OTC cold-and-cough section, only to be met by all sorts of cards to take to the pharmacy for pseudoephedrine, multiple rows of phenylephrine, as well as nasal sprays, antipyretics, and cough medicine. They are asking themselves, “Do I need just guaifenesin or guaifenesin with dextromethorphan or just dextromethorphan? Is it combined with acetaminophen and/or phenylephrine? Do I need something for day and something for night?” Let’s not mention the rows of antihistamines. Health care providers can help patients sort through the multiple available OTC options to treat symptoms of the common cold. Let’s educate patients regarding

treatment options for the most common acute illness in the United States, which is responsible for about 37 million doctor’s office visits every year.

Nasal decongestants, such as pseudoephedrine and phenylephrine, are used for short-term relief of nasal congestion and sinus pressure. What is the deal with pseudoephedrine, and why is it available only behind the counter at a pharmacy? Pseudoephedrine has been used illegally to produce methamphetamine, a highly addictive stimulant. The Combat Methamphetamine Epidemic Act of 2005, which was incorporated into the Patriot Act in 2006, mandated that retailers sell pseudoephedrine behind the counter only, require a photo ID, limit quantities purchased, and keep per- sonal information about the customers for at least 2 years.

Different states have different limitations. State governments have issued additional regulations because of the misuse of methamphetamine. I recently visited Arkansas and had a cold, and I could not purchase pseudoephedrine without identification from that state and was told by the pharmacist that I would need a prescription. Furthermore, certain pharmacies have additional regulations requiring a prescription, no matter what state a person is from. When recommending pseudoephedrine for patients, be aware of the state and pharmacy regulations. Waiting in line at the pharmacy for an OTC medication that can’t be purchased can be frustrating for patients with the common cold. As for effectiveness, results from studies have shown pseudoephedrine to be more effective than phenylephrine in reducing nasal congestion.

Keep in mind that alternative options may be preferred for patients with heart disease, hypertension, thyroid disease, diabetes, an enlarged prostate, or glaucoma.

Dextromethorphan (DXM) is a cough suppressant that is one of the more commonly abused cough and cold medicines. Misused at high doses, it can cause hallucinations and euphoria, referred to by teenagers and young adults as robotripping or skittling.

Interestingly, many brands combine DXM with guaifenesin. However, guaifenesin at high doses

induces nausea; needless to say, the combination brand is avoided by those with the intent to misuse. Patients should not take DXM with antidepressants because of the risk of serotonergic syndrome, which can be life-threatening.

Guaifenesin is an expectorant that works to thin mucous and clear congestion. Patients should know that if they drink a lot of water, this medication will be even more effective.

Saline nasal sprays are a safe and effective remedy to clear nasal congestion. Nasal sprays that contain a decongestant, such as phenylephrine, are also available. Tell the patient that decongestant nasal sprays should not be used for longer than 3 days, to avoid rebound nasal congestion. Very little research has been done on the effectiveness of nasal corticosteroids for the common cold. In my opinion, it may take several days for optimal symptom control, by which time the common cold will have resolved.

Antihistamines block histamine, which is responsible for allergic symptoms that are very similar to the symptoms of the common cold caused by a virus. This prompts the question, “Do antihistamines help relieve symptoms of the common cold?” Let’s review the evidence from 18 trials with 4342 participants reported in 17 different publications.

In adults, there was a benefit on the first or second day of treatment, with 45% feeling better versus 38% on placebo. But there was no difference over the remaining days. The trials in children were smaller and of lower quality, lacking evidence of effectiveness.

We will get through this season together, one cough at a time. Prevention is key. But educating patients about the appropriate OTC treatment options for them specifically can help improve symptoms and reduce the disruptions caused by the common cold.

, is a doctorally prepared family nurse practitioner with 9 years of experience in the retail health clinic industry.

She is the manager of clinic education and professional development at Walmart Care Clinic.

1.     Sexton DJ, McClain MT. Patient education: the common cold in adults (beyond the basics). UpToDate website

uptodate.com/contents/the-common-cold-in-adults-beyond-the-basics

. Updated March 1, 2016. Accessed November 1, 2017.

2.     Common cold: epidemiology. BMJ Best Practice website

bestpractice.bmj.com/best-practice/monograph/252/basics/epidemiology.html. Accessed November 1, 2017.

3.     Legal requirements for the sale and purchase of drug products containing pseudoephedrine, ephedrine, and phenylpropanolamine. US Food and Drug Administration website.

fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm072423.htm

. Updated on September 13, 2016. Accessed November 1, 2017.

4.     Horak F, Zieglmayer P, Zieglmayer R, et al. A placebo-controlled study of the nasal decongestant effect of phenylephrine and pseudoephedrine in the Vienna Challenge Chamber.

2009;102(2):116-120. doi: 10.1016/S1081-1206(10)60240-2.

5.     Cough and cold medicine abuse. National Institute on Drug Abuse website.

drugabuse.gov/publications/drugfacts/cough-cold-medicine-abuse

. Updated May 2014. Accessed November 1, 2017.

6. Drug Enforcement Administration. Dextromethorphan.

deadiversion.usdoj.gov/drug_chem_info/dextro_m.pdf

. Published March 2014. Accessed November 1, 2017.

7. De Sutter AIM, Saraswat A, van Driel ML. Antihistamines for the common cold.

cochrane.org/CD009345/ARI_antihistamines-common-cold

. Published November 28, 2015. Accessed November 1, 2017.

It is that time of year again, when health care providers see an increase in patient volume because no one has time to be sick. 

Treating the Common Cold

Incidence and acuity of type 2 diabetes in children increased significantly during the peak of the COVID-19 pandemic, according to a poster presented during the virtual 81st Scientific Sessions of the American Diabetes Association (ADA). The data collected from a retrospective chart review show that more pediatric patients were hospitalized from March to December 2020 at Our Lady of the Lake Children's Hospital in Baton Rouge, LA, compared to the same time period in 2019.

“While our study examined hospital admissions for type 2 diabetes in children at 1 center, the results may be a microcosm of what is happening at other children’s hospitals across the country,” said lead study author Daniel S. Hsia MD, associate professor at Pennington Biomedical Research Center in Baton Rouge, Louisiana, in a press release.

According to the ADA, there are a lack of data on the incidence or severity of new-onset type 2 diabetes in the pediatric population during the COVID-19 pandemic.1However, stay-at-home orders linked to the COVID-19 pandemic exacerbated risk factors for type 2 diabetes, including limited physical activity, increased screen time and sedentary behaviors, disrupted sleep, and increased intake of processed foods, which can all lead to weight gain.

According to the ADA, a national survey showed that more than 1 in 4 Americans with diabetes reported disruption to their ability to obtain healthy food during the pandemic. Modest weight gain over a short period of time can increase the risk for long-term health consequences, such as type 2 diabetes and cardiovascular disease.

The data analysis from Our Lady of the Lake Children’s Hospital found the following:

In 2019, the hospitalization rate for new onset type 2 diabetes was 0.27% for 2964 hospitalization cases compared to 0.62% of 2729 in 2020.

Children admitted to the hospital in 2020 had more severe diabetes with higher blood glucose, higher A1C, and higher indicators of dehydration compared to children admitted in 2019.

More children in 2020 also presented with serious conditions that typically require admission to the intensive care unit compared to 2019, such as diabetic ketoacidosis (8 vs. 3) and hyperosmolar hyperglycemic syndrome (2 vs. 0).

Twenty-three of 25 children were Black and 19 children were male.

“Unfortunately, COVID-19 disrupted our lives in more ways than we realize. Our study reinforces the importance of maintaining a healthy lifestyle for children even under such difficult circumstances,” Hsia said in the release.

New study shows hospitalization rates for new onset pediatric type 2 diabetes doubled during COVID-19 pandemic [news release]. June 25, 2021; ADA. Accessed June 25, 2021. [email]

New data alert: COVID-19 brings crisis of access for millions living with diabetes. ADA. Published December 23, 2020. Accessed June 25, 2021. 

https://www.diabetes.org/newsroom/press-releases/COVID-19-brings-crisis-of-access-for-millions-living-with-diabetes

Initial data show that children presented with higher acuity in 2020 compared to the previous year. 

Conferences

Study Links COVID-19 Pandemic to Increased Hospitalization Rates for Children With New Onset Type 2 Diabetes 

Weight loss is frequently a popular topic in the United States, with 73.6% of the population over the age of 20 years overweight and 42.5% obese.

However, the coronavirus disease 2019 (COVID-19) pandemic appears to be accelerating this. A quick search on Instagram reveals 59,600 results for the hashtag “#quarantine15.” Many of these results display people either sharing that they have gained weight during the pandemic or how they have managed to stave off the weight or even lose weight. Weight gain during the pandemic is not just a vanity concern on social media but is increasingly becoming a health concern that could lead to long-term health consequences for adults and children alike.

Survey results released by biotechnology company Gelesis in December 2020 showed that 71 million Americans had gained weight during the pandemic, and 63% had found it more difficult to maintain healthy lifestyle habits.

 The 71 million figure is extrapolated from an online survey among 1012 adults in the United States from October 26, 2020, to November 3, 2020. 2 Nonetheless, this shows that a significant number of Americans may be struggling to maintain a healthy weight during the pandemic. The disruption of daily lives, food insecurity, physical restrictions, and stress all play a role in gaining weight. Many people are also increasing their unhealthy snacking habits.

According to the results of an online cross-sectional survey between April 2020 and June 2020, participants reported increased consumption of salty snacks (37.4%) and sweets (43.8%),

Children are not immune to the pandemic weight gain. Prior to the pandemic, more than 20% of children ages 6 years and older were obese.1 Evidence is starting to show that limited access to healthy food and places to be physically active can increase a child’s risk for obesity.

Here are some tips to maintain a healthy weight:

 That means avoiding snacking while watching television or simply out of boredom. This can quickly increase calorie intake.

 Any snacks between meals should also be nutrient-dense. Avoid foods that are devoid of nutritional value. For example, a piece of whole fruit or raw vegetables with a side of hummus provide macro and micronutrients that make an individual feel full.

 Individuals who are given larger portions tend to eat more.5 The results of one study showed that increasing portions by 75% increased food intake by a mean 27% and 

 Adults can practice making appropriate portions by checking out MyPlate.gov and adhering to the recommended portion sizes. They should also be aware of the portions they are giving to children.

Drinking more water has myriad direct and indirect benefits. Drinking water instead of sweetened beverages can reduce overall caloric intake, but it also can help improve alertness, cognition, metabolism, and workouts; remove waste from the body; and suppress the appetite.

 Individuals should drink between 8 and 16 glasses of water each day, though amount should also be dictated by thirst and the color of urine. If the urine appears dark or concentrated, that indicates dehydration. Healthy urine is colorless or light yellow.

Meals should be full of nutritious foods. It may sound obvious, but many foods are overly processed and stripped of nutrients. This leads to calorie-laden food with little nutritional value. Ideally, the food should be a rich source of healthy macronutrients (healthy fats and sources of carbohydrates and high-quality protein) and micronutrients (minerals and vitamins), as well as lower in calories. Foods that are high in calories but low in nutritional value, such as candies, chips, and sweetened beverages, lead to weight gain and can increase the risk of cardiovascular disease and metabolic disorders. Foods that are high in fiber and protein provide vital nutrients but also help ward off hunger. Avoid both regular and sugar-free soda, as it is a huge culprit behind weight gain.

Studies have shown that insufficient sleep can increase hunger and lead to weight gain. How much sleep should people get?

 Newborn should sleep 14 to 17 hours a day, babies who are 12 months of age should sleep 10 hours at night and nap for 4 hours each day, two-year-olds should sleep 11 to 12 hours at night and have 1-to-2-hour afternoon nap each day, children age 3 to 5 years should sleep 10 to 13 hours a day, those 6 to 13 years of age should sleep between 9 and 11 hours each night, teenagers age 14 to 17 should sleep between 8 and 10 hours each night, and adults should get 7 to 9 hours’ worth of shut eye each night.

Fiber has many benefits, including helping with bowel regularity and a feeling of fullness. It can help lower cholesterol and stabilize blood sugar. Additionally, foods that are naturally high in fiber generally are healthier and offer other nutritional benefits. For example, fruits and vegetables are great sources of fiber but also are lower in calories and have antioxidants, minerals, and vitamins. Legumes are high in fiber and are also great sources of protein. Nuts and seeds are high in fiber, healthy fatty acids, minerals, protein, and vitamins.

 When individuals are stressed, it can lead to a rise in hormone levels that can cause craving fatty or sugary food and overeating. There are many ways to reduce stress, including asking for help, creating a relaxing nighttime routine, eating healthy, exercising, finding time for leisure, meditating, practicing yoga, prioritizing quality sleep, setting personal boundaries, spending time with family and friends, and taking a break from negative news.

 Both children and adults need to be physically active and should be active every day. Before the pandemic, 80% of Americans were not getting enough physical activity.

 Humans are meant to be active, and there is extensive research on the negative health consequences of being sedentary. Physical activity has myriad benefits, including reducing the risk of death from heart 

, and reducing anxiety, dementia, and depression. Physical activity also improves cognition and sleep. How much exercise is suggested? Children ages 3 to 5 years should be active throughout the day, while those who are 6 to 17 years should get at least 60 minutes of moderate to intense exercise each day.

 Adults should get 150 to 300 minutes of moderate exercise or 75 to 150 minutes of vigorous exercise each week.

Try an evidence-based diet or weight loss strategy.

 Avoid crash diets and dangerous trends. It is important that a diet be well-balanced and realistic for the long term. Crash diets tend to fail and lead to rebound weight gain, and there is no need to lose weight quickly. The key is to create a healthy lifestyle. One good plan to follow is the Mediterranean diet, which focuses on regularly consuming beans, flavorful herbs and spices, fruits, legumes, nuts, olive oil, vegetables, and whole grains; fish and seafood at least a couple of times a week; cheese, eggs, poultry, and yogurt in moderation; and red meats and sweets sparingly.

 Other diets may lead to more or faster weight loss, but many are lacking in nutrients and not sustainable. Individuals who are interested in intermittent fasting or low-carbohydrate diets should consult a health care professional for guidance to see if these methods are appropriate or safe for them and how to incorporate these into a healthy, well-rounded diet.

CDC. Obesity and overweight. Updated January 11, 2021. Accessed February 18, 2021. 

https://www.cdc.gov/nchs/fastats/obesity-overweight.htm

New survey finds 71 million Americans have gained weight throughout the pandemic [news release]. Boston, MA; December 22, 2020: Gelesis. Accessed February 17, 2021. 

https://www.gelesis.com/2020/12/22/new-survey-finds-71-million-americans-have-gained-weight-throughout-the-pandemic/

Bin Zarah A, Enriquez-Marulanda J, Andrade JM. Relationship between dietary habits, food attitudes and food security status among adults living within the United States three months post-mandated quarantine: a cross-sectional study. 

. 2020;12(11):3468. doi:10.3390/nu12113468

State of Childhood Obesity. Impact‌ ‌of‌ ‌the‌ ‌COVID-19 pandemic‌ ‌on‌ ‌childhood‌ ‌obesity‌‌. Accessed February 18, 2021. 

https://stateofchildhoodobesity.org/stories/impact-of-the-pandemic-on-childhood-obesity/

Zuraikat FM, Roe LS, Sanchez CE, Rolls BJ. Comparing the portion size effect in women with and without extended training in portion control: a follow-up to the Portion-Control Strategies Trial. 

. 2018;123:334-342. doi:10.1016/j.appet.2018.01.012

Johns Hopkins University. Yes, drinking more water may help you lose weight. The Hub. January 15, 2020. Accessed February 19, 2021. 

https://hub.jhu.edu/at-work/2020/01/15/focus-on-wellness-drinking-more-water/

Olson EJ. How many hours of sleep are enough for good health? Mayo Clinic. June 6, 2019. Accessed February 18, 2021. 

https://www.mayoclinic.org/healthy-lifestyle/adult-health/expert-answers/how-many-hours-of-sleep-are-enough/faq-20057898

Piercy KL, Troiano RP, Ballard RM, et al. The Physical Activity Guidelines for Americans. 

2018;320(19):2020–2028. doi:10.1001/jama.2018.14854

https://health.usnews.com/best-diet/mediterranean-diet

Weight gain during the pandemic is becoming a real health concern that could lead to long-term consequences for both adults and children. #quarantine15

Weight gain during the pandemic is becoming a real health concern that could lead to long-term consequences for both adults and children.

Help Patients Avoid the Quarantine 15

 an assistant clinical professor in urology at Georgetown, a urologic surgeon who specializes in the treatment of sexual dysfunction in both men and women, and one of only a handful of physicians trained in both female and male sexual medicine, on hypoactive sexual desire disorder (HSDD) and the current treatments available for this medical condition.

This Valentine's Day, do you have any guidance or thoughts for women or men who may have HSDD?

 My only advice is that sexual health is just health. If you are bothered by your libido, if you are bothered by your weak erections, if you are bothered by your inability to have a clitoral orgasm, see a doctor who knows about sexual health problems because not every doctor is trained in these really important issues.

Those of us who are [trained] care about them so much and want to find ways to improve quality of life because your quality of life and your sexual health really, really matters.

Rachel Rubin, MD, an assistant clinical professor in urology at Georgetown and a urologic surgeon, discusses ways of providing guidance to patients who may have hypoactive sexual desire disorder.

Expert: This Valentine’s Day, Nurses Can Remind Patients ‘Sexual Health Is Just Health’

The FDA has authorized expanded eligibility for the updated bivalent COVID-19 boosters for children between 6 months and 4 years of age, the agency announced today. Omicron variant-targeted booster shots made by Pfizer-BioNTech and Moderna were already available to individuals 5 years of age and older.

“More children now have the opportunity to update their protection against COVID-19 with a bivalent COVID-19 vaccine, and we encourage parents and caregivers of those eligible to consider doing so—especially as we head into the holidays and winter months where more time will be spent indoors,” FDA Commissioner Robert M. Califf, MD, said in a press release “As this virus has changed, and immunity from previous COVID-19 vaccination wanes, the more people who keep up to date on COVID-19 vaccinations, the more benefit there will be for individuals, families and public health by helping prevent severe illnesses, hospitalizations, and deaths.”

The FDA action authorizes children 6 months through 5 years of age who were administered the original monovalent Moderna COVID-19 vaccine to receive a single booster of the updated bivalent Moderna COVID-19 vaccine 2 months following completion of a primary series with the monovalent vaccine.

For children 6 months through 4 years of age who have yet to begin the 3-dose primary series of the Pfizer-BioNTech COVID-19 vaccine or who have not yet received the third dose of the primary series, the updated bivalent Pfizer-BioNTech COVID-19 vaccine can now be administered as the third dose in the primary series after 2 doses of the original monovalent vaccine.

Notably, children 6 months through 4 years of age who completed the 3-dose Pfizer-BioNTech COVID-19 primary vaccine series with the original monovalent vaccine are not eligible for the updated bivalent booster dose at this time.

“Children in this age group who already completed their primary series would still be expected to have protection against the most serious outcomes from the currently circulating omicron variant,” the FDA said in a press release. “The data to support giving an updated bivalent booster dose for these children are expected in January. The agency is committed to evaluating those data as quickly as possible.”

Both the Moderna and Pfizer-BioNTech bivalent COVID-19 vaccines include an mRNA component that corresponds to the original COVID-19 strain to induce a broadly protective immune response against COVID-19. The updated bivalent vaccines also contain an mRNA component that corresponds to the Omicron variant BA.4 and BA.5 lineages to confer superior protection against Omicron, according to the FDA.

In terms of adverse events (AEs), those administered the updated bivalent vaccines may experience similar AEs to individuals who were previously administered the original monovalent mRNA COVID-19 vaccines, according to the FDA.

“Vaccines remain the best defense against the most devastating consequences of disease caused by the currently circulating omicron variant, such as hospitalization and death. Based on available data, the updated, bivalent vaccines are expected to provide increased protection against COVID-19,” Peter Marks, MD, PhD, director of the FDA’s Center for Biologics Evaluation and Research, said in a press release. “Parents and caregivers can be assured that the FDA has taken a great deal of care in our review, and we encourage parents of children of any age who are eligible for primary vaccination or a bivalent COVID-19 vaccine booster dose to consider seeking vaccination now as it can potentially help protect them from COVID-19 during a time when cases are increasing.”

Coronavirus (COVID-19) Update: FDA Authorizes Updated (Bivalent) COVID-19 Vaccines for Children Down to 6 Months of Age. FDA. News release. December 8, 2022. 

https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-updated-bivalent-covid-19-vaccines-children-down-6-months

Booster shots updated for the Omicron variant BA.4 and BA.5 lineages cleared for children 6 months through 4 years of age.

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FDA Authorizes Bivalent COVID-19 Vaccine Booster for Children 6 Months to 4 Years of Age

Gastroesophageal reflux disease (GERD) is a common gastrointestinal (GI) disorder characterized by the regurgitation of stomach contents into the esophagus causing troublesome symptoms and/or damage to the esophageal mucosa.

GERD affects approximately 20% of the US population, and it is one of the most common GI disorders seen by health care practitioners in the outpatient setting.

The clinical manifestations of GERD are variable. Classic symptoms include heartburn and regurgitation or the flow of gastric contents into the upper esophagus and pharynx. Other clinical manifestations of GERD include belching, dysphagia, epigastric pain, nausea, and odynophagia. Extraesophageal symptoms can occur in an atypical GERD presentation, and they include asthma, chest pain, cough, dysphonia, hoarseness, and laryngitis.

Treatment of GERD requires a combination of lifestyle modifications and pharmacologic therapy. Lifestyle modifications for GERD include avoiding alcohol, avoiding foods that worsen symptoms, avoiding meals 2 to 3 hours before bedtime, elevating the head of one’s bed by 6 inches, and smoking cessation. Weight loss in patients who are obese or overweight also improves GERD.

The frequency and severity of GERD symptoms, and/or the presence of Barrett’s esophagus or erosive esophagitis guide pharmacologic therapy. Patients with mild symptoms that occur infrequently, such as less than twice per week, can use low-dose H2 receptor antagonists (H2RAs): cimetidine 200 mg twice daily; famotidine 10 mg twice daily; or nizatidine 75 mg twice daily. H2 antagonists can be used as needed, and they begin working within 60 to 90 minutes and last several hours.

 H2 antagonists are generally well-tolerated, though cimetidine can cause gynecomastia and impotence with long-term use. Cimetidine is a potent inhibitor of the P450 system and can cause drug interactions. Antacids can be used as needed for symptoms which occur less than once a week. Antacids containing aluminum hydroxide, calcium carbonate, or magnesium trisilicate combinations work within 5 to 10 minutes and last for up to an hour. Aluminum containing antacids may cause aluminum retention in patients with significant renal impairment.

Patients who have 2 or more episodes per week of GERD or with severe GERD symptoms who fail to improve with H2RAs and/or patients with erosive esophagitis require proton pump inhibitors (PPIs) therapy. Proton pump inhibitors, such as dexlansoprazole, esomeprazole lansoprazole, omeprazole, pantoprazole, and rabeprazole, taken once daily at standard dosages are recommended for 8 weeks.

PPIs are most effective when taken 30 to 60 minutes prior to meals, usually before breakfast. Patients who develop recurrent GERD symptoms after an 8-week PPI course can be retreated with repeated 8-week courses and may require long-term maintenance therapy. Patients with early (<3 months of discontinuing acid suppression) and/or refractory recurrent symptoms may require referral for an upper endoscopy.7

PPIs are associated with adverse effects, particularly with long-term therapy. GI effects include increased risk for enteric infections, including C. difficile and multi-drug resistant Enterobacterales colonization. Long-term PPIs can cause malabsorption of minerals and vitamins, specifically hypomagnesemia, and vitamin B12 and PPIs may affect oral iron absorption. Long-term PPI therapy may slightly increase the risk for fractures of the hip, spine, and wrist. Patients with risk factors for osteoporosis who require PPIs should take calcium citrate and vitamin D supplements.

 PPIs can cause acute interstitial nephritis, and they may increase the risk for the development or progression of chronic kidney disease.

 PPIs may increase the risk for pneumonia, particularly in patients who are hospitalized.

Lifestyle modifications are recommended for all patients with GERD. Patients with infrequent, intermittent, or mild symptoms can use low-dose histamine 2 receptor antagonists, such as antacids or famotidine, as needed. Patients with erosive esophagitis, failure to respond to H2As, or frequent or severe symptoms require once-daily standard dose PPIs for 8 weeks.

1. El-Serag HB, Sweet S, Winchester CC, Dent J. Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review. 

 2014;63(6):871-880. doi:10.1136/gutjnl-2012-304269

2. Peery AF, Dellon ES, Lund J, et al. Burden of gastrointestinal disease in the United States: 2012 update. 

2012;143:1179-1187.e3. doi:10.1053/j.gastro.2012.08.002

3. Hom C, Vaezi MF. Extraesophageal manifestations of gastroesophageal reflux disease. 

 2013;42(1):71-91. doi:10.1016/j.gtc.2012.11.004

4. Katz PO, Dunbar KB, Schnoll-Sussman FH, et al. ACG clinical guideline for the diagnosis and management of gastroesophageal reflux disease. 

. 2022;117(1):27-56. doi:10.14309/ajg.0000000000001538

5. Richter JE, Vaezi MF. Gastroesophageal reflux disease. In: Feldman M, Friedman LS, Brandt LJ, eds. 

Sleisenger and Fordtran's Gastrointestinal and Liver Disease.

6. Kahrilas PJ, Howden CW, Hughes N. Response of regurgitation to proton pump inhibitor therapy in clinical trials of gastroesophageal reflux disease. 

. 2011;106(8):1419-1425;quiz 1426. doi:10.1038/ajg.2011.146

Treatment of gastroesophageal reflux disease requires a combination of lifestyle modifications and medications. 

Kimberly J. Henderson, MD, JD

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