In this may indicate a more severe disease process

In addition tolifestyle modifications (discussed below), low-dose famotidine is administeredas 10 mg every 12 hours.  Kahrilas (2016)suggests starting with lifestyle modifications and progressing to a low-doseH2RA; however, because lower esophageal sphincter tone becomes more relaxedwith aging, this NP will initiate therapy with both low-dose famotidine and therecommendation of lifestyle modifications. The patient will be assessed at the end of two weeks to determine iftherapy is effective.

  For continuedsymptoms despite therapy, famotidine will be increased to the standard dose of20 mg every 12 hours for six weeks, followed by maintenance dosing at 20 mgonce daily at bedtime for up to six weeks (Woo & Robinson, 2016).  For those with renal impairment withcreatinine clearance less than 50 mL/min, 50% of the dose should be given, orthe dosing interval should be increased to every 36 to 48 hours (Lexicomp,2017).  Tachyphylaxis may develop withintwo to six weeks after initiation of the drug, limiting its use as maintenancetherapy (Kahrilas, 2016).  For thisreason, H2RAs are not recommended for first-line continuous treatment of GERD (Woo& Robinson, 2016).  For persistent orworsening symptoms of GERD, the patient should notify the provider, as this mayindicate a more severe disease process and alternative therapies may bewarranted.Monitoring            Complete bloodcounts may be obtained at annual visits to monitor for anemia caused by upperor lower GI bleeding from complications of the disease (Woo & Robinson, 2016).  Because side effects of famotidine includethe potential for hepatocellular damage as evidenced by cholestatic jaundice,hepatitis, and other GI-related symptoms, patients requiring stronger doses orlonger courses of therapy should have laboratory testing to measure liverfunction at regular intervals throughout therapy (Woo & Robinson, 2016; Lexicomp,2017).

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  Those with renal impairment or athigh risk for renal impairment should have renal function tests beforebeginning treatment and throughout the course of therapy (Woo & Robinson,2016).  An endoscopy may be required forpatients requiring continuous therapy with H2RAs, as it is used to detect thepresence of lesions (Woo & Robinson, 2016). Continuous therapy may also warrant an endoscopy every two to threeyears given the irreversible nature of complications such as Barrett’sesophagus (Woo & Robinson, 2016).    PatientEducationAdministration.Thepatient should be educated on the appropriate timing of the administration offamotidine to achieve optimal effects, which is with meals or immediatelyafterward and at bedtime (Woo & Robinson, 2016).  The full course of therapy should becompleted and taken as prescribed (Woo & Robinson, 2016).  Missed doses should be taken as soon asremembered unless it is almost time for the next dose (Woo & Robinson,2016).  Additional patient educationrelated to administration of the drug has been mentioned previously.

AdverseReactions. The patient should be educated about famotidine’sside effects that may cause hazardous conditions, such as drowsiness anddizziness, and to avoid activities that require mental alertness until responseto the medication is known (Woo & Robinson, 2016).  The patient should know what symptoms toreport to their provider, such as black, tarry stools, sore throat, diarrhea,rash, confusion, or hallucinations (Woo & Robinson, 2016).  Constipation may occur and should be remediedby increasing fluids and fiber in the diet (Woo & Robinson, 2016).  Lifestylemodifications.

A number of lifestyle modifications can beemployed to assist in remedying the symptoms of GERD.  Anti-reflux maneuvers include sleeping withthe head of the bed elevated six to eight inches, avoiding exercising orbending over within three hours of eating, and preserving or obtaining ahealthy body weight (Woo & Robinson, 2016). Dietary considerations include the following: avoiding foods that arespicy, acidic, tomato-based, fatty foods, chocolate, peppermint, onions, andcitrus fruits and juices; limiting caffeine intake; not over-eating; avoidingeating within three hours of bedtime, and avoiding copious amounts of fluidintake during meals (Woo & Robinson, 2016). Smoking cessation is a high priority, as nicotine relaxes the loweresophageal sphincter and allows for regurgitation of stomach acid, causing theburning sensation that is common with GERD (Woo & Robinson, 2016).  The patient shouldbe aware that the goal of treatment is the relief from GERD symptoms.  The patient should also be educated aboutdisease process and to be able to fully understand why lifestyle modificationsmay positively impact the quality of life.

 For example, increased intra-abdominal pressure caused by vomiting, coughing,over-eating, and bending over contribute to GERD symptoms (Woo & Robinson,2016).  The patient should also be awareof symptoms that suggest potential and serious complications of thedisease.  These include dysphagia andpainful swallowing, noncardiac chest pain, the presence of an abdominal mass,hematemesis/melena, anemia, weight loss, and choking (Woo & Robinson, 2016).