Reply to these post with 300-350 words for EACH post. Post 1 What lifestyle modifications do you recommend for CF? The lifestyle modifications that I would recommend for CF would include losing weight if he is overweight, raising the head of bed at night by adding pillows so his head is above his heart/stomach which can prevent acid from rising and will decrease the nighttime heart burn, avoiding eating late at night, avoiding large meals, to not lay down immediately after a meal, wearing loose comfortable clothing, and although he states he does not smoke anymore I would reiterate quitting smoking (Kahrilas, 2021). Other recommendations that I would make are specifically related to avoiding triggering foods. Triggering foods for heartburn and causing GERD flares are caffeine, chocolate, peppermint, spicy foods, and some fatty foods (Kahrilas, 2021). I would also encourage CF to keep a food journal which would allow him to pinpoint foods that bother him specifically. Describe a rational drug choice for this patient. Be specific regarding what factors you would consider. Include pharmacokinetic and dynamic considerations for the pharmacological choices made. Also consider interactions and side effects. The rational drug choice for this patient would be a proton pump inhibitor (PPI). I would prescribe this because CF has already tried an H2 receptor antagonist and antacids with no relief so a PPI would be the next first line choice (Woo et al., 2020). Kahrilas (2020), states that PPIs are the most effective medications for reducing stomach acid and H2 receptor antagonists can reduce stomach acid but are not usually effective in moderate to severe symptoms. PPIs work by reducing gastric acid secretion in the stomach by blocking the mechanism of action of parietal cells (Woo et al., 2020). Parietal cells are cells found in the stomach wall and their role is to secrete acid. Gastric acid secretion is reduced by inhibiting the H+/K+/adenosine triphosphatase (ATPase) enzyme system found in the parietal cell (Woo et at., 2020). CF is appropriate for a PPI as it is approved for adults, he is male so there is no pregnancy risk as it is category B/C, and he is 48 so there is no concern for the use of it in an older adult (Woo et al., 2020). Before I started CF on a PPI I would run a liver panel and make sure that CFs liver function was normal as PPIs are metabolized in the liver and are contraindicated in patients with hepatic dysfunction (Woo et al., 2020). Hicklin (2017) found that blocking stomach acid can add to and affect liver damage, so ensuring that a patient’s liver is functioning at a normal level is incredibly important before starting them on a PPI. I would explain to CF that there are possible adverse drug reactions that we would watch for. PPIs can put the patient at risk for interactions with other medications due to interrupting the drug absorption so we would go over his mediation list (Woo et al., 2020). There is also a risk for vitamin deficiencies so ensuring that he is eating a healthy diet full of fruits and vegetables would be necessary (Woo et al, 2020). CF is also at risk for pneumonia and with long term use of a PPI, osteoporosis and hip fractures especially because he works a sedentary job so, when he is not at work making sure he gets enough exercise is crucial (Woo et al., 2020). As a future APRN anytime I start a patient on a new medication I want them to understand why they are on the medication, the benefits of taking it, but to also have an understanding of the side effects and adverse effects. What counseling points about this medication do you give CF? There are a few counseling points about this medication that I would explain to CF. First, I would explain that I would start CF on a daily dose of a PPI. I would start him on a daily dose and then if symptoms are not resolving or only slightly better than we can increase to twice daily (Woo et al., 2020). Secondly, I would explain that it is important for CF to take this medication daily before breakfast (Fass, 2021). This will help reduce acid before eating and if he takes a second dose it would be important to take this dose before dinner. I would then explain that it is important for CF to be medication compliant. Last, I would tell CF about possible side effects of PPIs which can include diarrhea, nausea, vomiting, and rebound heart burn if CF stops the PPI abruptly (Ambizas, 2017). I would counsel CF to report these side effects to me if they occur. post 2 1. What lifestyle modifications do you recommend for CF? Lifestyle modifications would include no food or drink before bed, continued smoking cessation, dietary changes and elevation of the bed (Woo & Robinson, 2020). Dietary changes should include stopping foods that can potentially aggravate reflux symptoms including caffeine, coffee, chocolate, spicy foods, highly acidic foods such as oranges and tomatoes, and foods with high fat content (Katz et al., 2013). The role of alcohol with GERD is still controversial with some reports suggesting alcohol weakens the esophageal motility and reduces pressure of lower esophageal sphincter while other studies finding no relation of alcohol and risk of reflux (Pan et al., 2019). 2. Describe a rational drug choice for this patient. The drug choice for this patient after lifestyle modification would be a proton pump inhibitor or a PPI. This patient has tried over the counter antacids with minimal effect and for this reason PPIs are the first line treatment that is recommended (Woo & Robinson, 2020). Symptom history of regurgitation and heartburn are the most reliable for making a diagnosis based on history alone (Katz et al., 2013). Signs and symptoms include burning substernal pain that radiates upward that can be increased after meals and laying down, sore throat, hoarseness, halitosis and halitosis (Woo & Robinson, 2020). The patient has a diagnosis of GERD by endoscopy and his symptoms correlate with this diagnosis. Proton pump inhibitors decrease the acid secretion by 100% by binding to the enzyme hydrogen, potassium ATPase (Woo & Robinson, 2020). Patients with hepatic impairment may need lower doses of PPI (Woo & Robinson, 2020). PPIs also interact with warfarin, phenytoin, diazepam, and clopidogrel (Woo & Robinson, 2020). Other side effects include diarrhea, stomach pain, headache and potential interference with food and minerals (H2 blockers & PPI, 2019). There are also long term effects to consider like reduced Calcium absorbtion, decreased Magnesium and rebound gastric secretions (H2blocker & PPI, 2019). 3. What counseling points about this medication do you give CF? CF would be counseled on how to take the drug and on the importance of assessing the symptoms after 4 weeks of therapy and if there is no improvement the patient need to know that they will be referred to a specialist (Woo & Robinson, 2020). CF will also be counseled about the importance of lifestyle modifications and the importance and side effects of the drug. use APA format and 3 or more reference. Your responses should be in a well-developed paragraph (300-350 words) to each peer. Integrating an evidence-based resource that is different than the one you used for the initial post. Respectfully agree and disagree with your peers responses and explain your reasoning by Including your rationales in your explanation.