ICBL-I

Patient Work-up (SOAP Format)

Students’ Names:
- Jana Abou Khzam
- Nour Al Masry
- Mohamad Al Zoghby
- Mahmoud Dada

Patient Initials: S.S. Medical Condition(s): GERD

Patient Profile Summary:

1. Name: Samer Swaydan

2. Gender: Male

3. Age: 27years old

4. Race: White

5. BMI: Weight/height2 = 74/(163)2= 27.9 ( overweight)

6. Social history:
 Smoking status: non smoker
 Alcohol consumption: non alcoholic
 marital status: married
 Medical coverage: NSSF

7. Lifestyle:
 Diet: nonspecific diet
 Physical activity: Sedentary lifestyle, does not exercise.

8. Allergy: NKFDA

9. past medical history: GERD since 2018

10. Home medication: Rennie® (calcium carbonate 680mg, Magnesium carbonate 80mg) chewable
tablet.

11. No herbal product/ otc taken

12. Adherence: Good

13. Any preference/ values: he prefers tablets.

14. Chief complaint: Suffering from heartburn and feeling like food is coming back into the mouth
leaving an acid or bitter taste.

15. Diagnosis: GERD since 2018.

16. No relevant Lab tests.

17. Medication of present illness: none.

 Patient SOAP notes:

SUBJECTIVE Chief complaint : heartburn

Feeling that the food is coming back out into the mouth and leaving a bitter metallic ta

OBJECTIVE GERD diagnosis since 2018.

ASSESSMENT This is a case of actual indication DRP. This is a case of a 27 year old patient suffering
(Include DRP, GERD and is taking Rennie to relieve his heartburn. This medication is not effective in
medical condition treating GERD, so he should be started on proton pump inhibitors (Omeprazole,
assessment and Pantoprazole, Rabeprazole). Taken once daily in the morning 30 minutes before his firs
references) meal.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1936305/

1. Goals Alleviate the patient from his heartburn and the bitter taste from food coming out of his
a. Clinical mouth.
outcomes

b. Short Term Decrease the frequency of gastroesophageal reflux

Goals Promote healing of his mucosa
c. Long Term Prevent complications
Goals Improve quality of life

2.Alternatives Addition of h2 blocker Famotidine at bedtime to increase the efficacy of treatment

No other alternatives

3.Therapeutic Pharmacological :
Plan PPI(omeprazole) Gastrimut 20mg 1 pill once daily in the morning 30 mins before first m
for 2 months
Non-pharmacological :
-Weight loss

-Dietary improvements: eating healthier, avoid eating 3 hours before bedtime

-Elevation of head when sleeping

-Don’t wear tight clothes

-Avoid foods and drinks that trigger reflux tomato sauce, mint, garlic, caffeine

Counseling Do not take medication containing salicylates, ibuprofen

If there is severe diarrhea consult your nearest health care professional.

 4. Monitoring Efficacy clinical: relief from symptoms
Parameters Safety clinical: headache, dizziness, diarrhea, chest pain.
Safety lab: AST,ALT
PLAN

FOLLOW- UP 5 to 7days after beginning of treatment to check for symptoms relief.

set with patient for
next visit
 GERD DIR

1. When should a patient undergo gastric endoscopy?

Patients should undergo gastric endoscopy when some symptoms called “alarming
symptoms” are present. These alarming symptoms include: dysphagia (difficulty in
swallowing), odynophagia (painful swallowing) and unexplained weight loss. Also
endoscopy must be done in case the patient is at high risk for GERD complications such
as esophagitis and mucosal damage or having atypical symptoms such as non-cardiac
chest pain. It is also recommended for patients who are unresponsive to PPIs.
References:

- Pharmacotherapeutic Lecture
- American Journal of Gastroenterology, Guidelines for the Diagnosis and Management of
Gastroesophageal Reflux Disease 2013.

2. What are the major side effects of long term intake of PPIs?
Long term use of PPIs may cause major side effects that include:

 Micronutrient deficiency (decrease absorption of calcium, vitB12,

Magnesium…).
 Hypomagnesaemia leading to tetany, seizures, increase risk of diabetes and
cardiovascular disease.
 Increase risk of hip, wrist and spine fracture (due to decrease calcium
absorption).
 Clostridium difficile colitis leading to diarrhea.
 Gastric carcinoid due to hypochlorhydria.
 Pneumonia (mainly in short term use)
 Dementia.
 Kidney disease.
References:

- PubMed “the risk of long term use of PPIs: a critical review”

- American Journal of Gastroenterology, Guidelines for the Diagnosis and Management of
Gastroesophageal Reflux Disease 2013.

3. State in a table form the trade names, generic name and dosage regimen of the
available proton pump inhibitors in the Lebanese market.
Trade Name Generic Name Dosage Regimen

ARAPRIDE Omeprazole 20-40mg

AXIPRON Omeprazole 10-20-40mg

BELMAZOL omeprazole 20mg

DANLOX QUICK Omeprazole+sodium 20mg-1680mg

bicarbonate

DIGCAP omeprazole 20mg

EPIRAZOLE omeprazole 20mg

ESELAN Omeprazole 40mg

GASTRAZOLE Omeprazole 20mg

GASTRIMUT omeprazole 20mg

GASTRISEC Omeprazole 20mg

HYPOSEC Omeprazole 20mg

IPPROTON Omeprazole 40mg

LOZICARE Omeprazole 40mg

NEOOPRAZOLE Omeprazole 20mg

ODASOL Omeprazole 20mg

OMEDAR Omeprazole 20mg

OMEPRAL Omeprazole 10-20-40mg

OMEPRAZOLE ARROW- Omeprazole 40-20-40mg

PHARMADEX-VIANEX

OMEZOL BENTA Omeprazole 20mg

OMIZ-OMIZ PLUS Omeprazole 20-40mg

OPRAZOLE Omeprazole 40mg

REMEPRAZOLE Omeprazole 20mg

RISEK Omeprazole 10-20-40mg

ULCAZAL Omeprazole 40mg

ULCESEP Omeprazole 20mg

ULSTOP Omeprazole 20mg

ULZOL Omeprazole 20mg

APO-ESOMEPRAZOLE Esomeprazole 20-40mg

ESAC Esomeprazole 40mg

ESO-TAD Esomeprazole 20-40mg

ESOMEP Esomeprazole 20-40MG

ESOMEPRAZOLE ARROW- Esomeprazole 20-40-40-40mg

GENFARMA-NORMON

EXONAR Esomeprazole 20-40mg

METAPRO Esomeprazole 40mg

NEXIUM Esomeprazole 10-20-40mg

NEXPRAZOL Esomeprazole 20-40mg

PRIMAZOL Esomeprazole 20-40mg

PUMPINOX Esomeprazole 40mg

JOSWE LANZOTEC Lansoprazole 15-30mg

LANSAZOL Lansoprazole 30mg

LANSOMID Lansoprazole 30mg

LANZOR Lansoprazole 30mg

LPZ Lansoprazole 30mg

PEPTAZOLE Lansoprazole 15-30mg

TAKEPRON Lansoprazole 15-30mg

GASTROPAN Pantoprazole 20-40mg

LUGANOR Pantoprazole 40mg

PANTHRON Pantoprazole 40mg

 PANTO-TAD Pantoprazole 20-40mg

PANTOMAX Pantoprazole 20-40mg

PANTONIX JULPHAR Pantoprazole 40mg

PANTOPRAZOLE AZEVEDOS- Pantoprazole 40mg

SALA

PANTOVER Pantoprazole 40mg

RAZON Pantoprazole 20-40mg

PARIET Rabeprazole 10-20mg

PRASOLAN Rabeprazole 10-20mg

PULOROS Rabeprazole 20mg

RABEC Rabeprazole 10-20mg

RABEZOL Rabeprazole 10-20mg

RAMEP Rabeprazole 10-20mg

RAZOLE Rabeprazole 10-20mg

REBACIP Rabeprazole 10-20mg

REFLUZOL Rabeprazole 10-20mg

DEXILANT Dexlansoprazole 30-60mg

References: Lebanese National Drugs Database

4. Should all PPI be taken before meal? if not , name one(s) that can be taken regardless to
meals.

All PPIs should be taken before meals except one which is DEXLANSOPRAZOLE
(Dexilant®). Dexlansoprazole can be taken with or without food, its efficacy is not
dependent on meals which provide better compliance and cooperation with the patient
and ensure higher efficacy. So patient can take it with regards to meal times and drug
intake at specific times in relation to meals which would have a positive impact on
patient adherence and compliance.
References: PubMed “Dexlanzoprazole: a new generation of proton Pump Inhibitors”.

5. Patient came to the pharmacy asking you if she can take Pariet® 20 mg with the
following home medication: PANADOL- EUTHYROX .If yes , write down briefly how
should she take them.

Pariet® (Rabeprazole) has no known drug interaction with Euthyrox® (levothyroxine)

and Panadol® (acetaminophen).
After 6 months of PPIs therapy, patient taking levothyroxine could require an increase in
their dose because PPIs can affect their absorption.
 Pariet should be taken 20 mg once daily in the morning ½ an hour before meals for four
weeks.
 Panadol ® 650mg should be taken every 4 to 6 hours (maximum dose should be less
than 4g).
 Euthyrox® 100mg (should be taken 4 hours before or after PPIs such as pariet) so in this
case this medication should be taken once daily first one in the morning ½ or 1 hour
before meals, then pariet should be taken also ½ an hour before meals. Most
importantly, this medication should be taken same time every day.
References:

- Drug Information Handbook

- Medscape

6. A patient came to the pharmacy complaining from heartburn. After further investigation
you noticed he smokes 25 cigarettes/day and drinks 2 cups of wine daily. Are smoking
and alcohol causative agents for the heart burn and how ?

Sure, smoking and alcoholic consumption are main risk factors for heartburn (a
symptom of gerd) because tobacco smoke stimulate the stomach acidity by prolonging
acid clearance time due to reduced salivary secretion and cause the relaxation of
muscles between the esophagus and the stomach by reducing lower esophageal
sphincter pressure (due to the bloackde of cholinergic receptors by nicotine) which
stimulate the reflux of stomach acidity into the esophagus causing heartburn.
Also, alcohol consumption might decrease lower esophageal sphincter pressure.
Moreover alcohol can have direct effect on the esophageal mucosa which can cause
mucosal injury leading to heartburn and GERD symptoms.
References:

- PubMed “tobacco smoking, alcohol consumption and GERD”.

 GERD Disease Counseling

Hello Mr. How are you doing? I am your pharmacist ……. How may I help you? May I know your
name?

Mr. Samer do you mind having a counseling session for about 5 minutes if you’re available? This
session will be done to ensure you have the optimal knowledge about your disease, treatment
plan, and to answer all your questions and concerns. Do you prefer to take in a private area?

Well Mr. S.S, you’re diagnosed with Gastroesophageal reflux disease (GERD) that occurs when
stomach acid frequently flows back into the tube connecting your mouth and stomach
(esophagus) due to abnormal sphincter relaxation or weakening. This backwash (acid reflux) can
irritate the lining of your esophagus.

The most common symptoms of GERD are:

 Heartburn, usually after eating, which might be worse at night

 Belching
 Regurgitation of food or sour liquid
Other symptoms include:

 Chronic cough
 Laryngitis
 Disrupted sleep
 Chest Pain

- If left untreated, the chronic inflammation in your esophagus can cause several
complications including:

 Narrowing of the esophagus (esophageal stricture). Damage to the lower esophagus from
stomach acid causes scar tissue to form. The scar tissue narrows the food pathway,
leading to problems with swallowing.

 An open sore in the esophagus (esophageal ulcer). Stomach acid can wear away tissue in
the esophagus, causing an open sore to form. An esophageal ulcer can bleed, cause pain
and make swallowing difficult.

 Precancerous changes to the esophagus (Barrett's esophagus). Damage from acid can
cause changes in the tissue lining the lower esophagus. These changes are associated with
an increased risk of esophageal cancer.
-As for you medication treatment, you are recommended to take:

Gastrimut® 20 mg PO once daily for 8 weeks 30 minutes before your first meal

This medication helps heal acid damage to the stomach and esophagus, and relief your
symptoms of heartburn and discomfort.

-Other than your medication, lifestyle changes may help reduce the frequency of acid reflux.
That is why I advise you to try to:

 Maintain a healthy weight. Excess pounds put pressure on your abdomen, pushing up
your stomach and causing acid to reflux into your esophagus.

 Don't lie down after a meal. Wait at least three hours after eating before lying down or
going to bed.

 Eat food slowly and chew thoroughly. Put down your fork after every bite and pick it up
again once you have chewed and swallowed that bite.

 Avoid foods and drinks that trigger reflux. Common triggers include fatty or fried foods,
tomato sauce, alcohol, chocolate, mint, garlic, onion, and caffeine.

 Avoid tight-fitting clothing. Clothes that fit tightly around your waist put pressure on your
abdomen and the lower esophageal sphincter.

- Thank you for your time Mr. S.S. if you have any questions I am ready to answer them.

References:

- https://www.mayoclinic.org/diseases-conditions/gerd/diagnosis-treatment/drc-
20361959
- ACG Clinical Guideline 2013
 GERD Medication Counseling

Medication: Gastrimut 20mg

Hello Mr. hope you are doing well.

Let me introduce myself I’m pharmacist… ready to help you.
Now I would like to know your name please.
Mr. Samer for whom is this prescription?
Since you are the patient I would like to take 5 minutes from your time so I can clarify
few details about your medication after your permission of course.
Do you prefer keeping our conversation in private or you don’t mind talking here?
Okay Mr. Samer first of all I have some questions for you. So Mr. what are you using this
medication for? How are you using this medication? How is this medication working for
you?
Thank you for your answers. I would like to start with some indication about this
medication. Gastrimut is a gastroprotective given to treat the heartburn caused by
GERD.As for the mode of action it contains active component called Omeprazole which
acts by blocking the proton pump that causing the gastric acid secretion and thus your
heartburn. The recommended dose is taking one tablet (20mg) once daily for 8 weeks.
Take this medication once daily before meals by one hour. The heartburn must be
relieved after 5-7 days. If you missed a dose take the medicine before the next meal in
12 hours interval from the following dose. Don’t double the dose! You might suffer from
headache, nausea, vomiting, flatulence… Stop using gastrimut and call your doctor if you
suffer from severe stomach pain, diarrhea that is watery or bloody. Store gastrimut at
room temperature away from light and moisture.
Please I would like to hear from you how you are going to take your medication and
what are the side effects that you may suffer from? Please restate what I said regarding
the missed dose.
I hope everything is clear, please I would like to know if you have further questions.
Thank you Mr. Samer for your time, hope you will get better soon.

References:

- Medscape
- Ncbi