POST 1
A 30-year-old man presents to his doctor because of heartburn for the past 8 weeks. He says he feels a burning sensation in his epigastric area that is usually worse after eating certain foods and if he lies down after eating. His symptoms used to be only once or twice a week but are now daily. He has been trying lifestyle modifications; he quit drinking coffee and is working on weight loss for the past couple of months, but the symptoms have not improved. A review of systems is negative for any history of cough, difficulty swallowing, hematemesis, or melena. He reports often drinking a can of beer in the evening after work and does not smoke. His blood pressure is 124/82 mm Hg, heart rate is 72/min and regular, and respiratory rate is 14/min. BMI is 29 kg/m2. There is no abdominal tenderness on the physical exam. Which of the following is most efficacious in the management of this patient?
Correct answer: Start omeprazole once daily
This patient most likely has gastroesophageal reflux disease (GERD), which presents as a burning sensation in the chest, aggravated by spicy and fatty foods, alcohol, smoking, and lying down after meals.
Initial management of GERD involves weight loss, avoiding triggers (e.g., spicy/fatty foods, alcohol, caffeine), and smoking cessation. The optimal initial pharmacologic management for GERD is controversial; however, for patients with daily symptoms that have not improved with lifestyle changes, the usual recommendation is to start a daily proton pump inhibitor (PPI) such as omeprazole.
Omeprazole and other PPIs act by inhibiting the final step in the secretion of H+ ions from the parietal cells of the stomach. PPIs accumulate within the parietal cells of the stomach and are activated by the acidic environment. They irreversibly block the H+/K+ ATPase (gastric acid pump) responsible for secreting H+ ions into the gastric lumen. This is the final step in gastric acid production, and its inhibition significantly relieves GERD symptoms.
The management choice of starting omeprazole once daily for this patient is appropriate for several reasons:
- Symptom severity and duration: The patient has been experiencing heartburn for the past 8 weeks, and it has progressed from once or twice a week to daily. This indicates a need for pharmacological intervention, as lifestyle modifications alone have not been effective.
- Typical symptoms: The patient’s symptoms, characterized by a burning sensation in the epigastric area that worsens after eating and when lying down, are typical of gastroesophageal reflux disease (GERD).
- Lifestyle modifications: The patient has already attempted lifestyle modifications by quitting coffee and working on weight loss, but these efforts have not improved his symptoms.
- Safety and efficacy of proton pump inhibitors (PPIs): PPIs like omeprazole are highly effective in reducing gastric acid production, making them a suitable choice for GERD management. They are generally safe and well-tolerated.
- Gradual progression: Initiating with PPI therapy aligns with the step-up approach to GERD management. If symptoms do not improve with PPI therapy, further evaluation and management can be considered, such as endoscopy to assess for complications like esophagitis or Barrett’s esophagus.
Overall, starting omeprazole once daily is a reasonable and effective initial approach to manage this patient’s GERD symptoms. However, continued follow-up is necessary to assess the patient’s response and make adjustments as needed.