Acid peptic disease

Question 1

Classification of drugs in acid peptic disease

Answer 1

1. Acid suppressants ((PI, H2 blockers, antimuscarinic, Prostanglandins - Misoprostol)
2. Acid neutralisers- Antacids - prompt pain relief
3. Ulcer protectives - Sucralfate, bismuth compounds
4. Antibiotics for H Pylori
5. Miscellaneous - antifoaming (alginic acid) in GERD, antiflatulence (Simethicone)

Question 2

Acid suppressants

Answer 2

1. Anticholinergic - Pirenzepine, Telenzepine
   atropine like SE
2. H2 blockers - Cimetidine, Ranitidine
3. PPI - Omeprazole, Pantoprazole
   most effective

all 3 reduce meal induced acid production but anticholinergic cant reduce nocturnal acid production therefore not used nowadays

Question 3

PPIs

Answer 3

Dexrabeprazole (most potent)
Ilaprazole
Lansoprazole
Rabeprazole
Omeprazole
Pantoprazole (least potent)

all are equally effective

Question 4

Routes of PPIs

Answer 4

oral - all drugs
inj - iv or im - Pantoprazole, Es-Omeprazole, Rabeprazole

Question 5

fasting acting PPI

Answer 5

Omeprazole

Question 6

active form of PPIs

Answer 6

sulfenamide moeity

Question 7

All PPI metabolised by
which other drug

Answer 7

CYP2C19

Clopidogrel

Question 8

PPI with max CYP inhibitor

Answer 8

Omeprazole

Question 9

PPI with least CYP inhibitor

Answer 9

Rabeprazole> Pantoprazole

Question 10

uses of PPI

Answer 10

doc for peptic ulcer due to any cause (H Pylori/ NSAID induced)

doc for GERD (reduce HCl production and close LES- prokinetics like Domperidone and Mosapride)

iv PPI for gastric bleeding

aspiration pneumonia (PPI + prokinetics)

Zollinger Ellison (gastrinoma) - Octreotide (suppress gastrin production) + PPI (suppress HCl)

Question 11

Adverse effect of PPI

Answer 11

Fe deficiency anemia
osteoporosis
Mg deficiency
Vit B12 def but megaloblastic anemia not seen

Clostridium difficile infection (pseudomembranous colitis)
Community acquired pneumonia
Spontaneous bacterial peritonitis

Gastric polyps
Omeprazole can cause gynaecomastia and impotence
Long term use can cause renal failure and Alzheimer’s

Question 12

PPIs in pregnancy

Answer 12

safest: Lansoprazole> rest others
unsafe: Omeprazole

Question 13

H2 blockers

Answer 13

more preferred over PPI in stress ulcer

Cimetidine - least potent, CYP inhibitor
Ranitidine
Famotidine - non competitive blocker
Roxatidine
Nizatidine - no CYP inhibition
Lafutidine - increase somatostatin level

Question 14

Acid suppressant which is a Prostanglandin E1 analogue

Answer 14

Misoprostol
reduces HCl Production and increase mucus or bicarbonate production

only in NSAID or aspirin induced peptic ulcer but doc is still PPI

Question 15

new PPI

Answer 15

Tanatoprazole - reversible inhibitor of H+ K+ ATPase

Vonoprazan, Revaprazan - competitive blocker of K+ site in H+ K+ ATPase
Adv - not metabolised by CYP2C19

Question 16

New Prostanglandins

Answer 16

Carbenexolone (increases aldosterone synthesis and causes hypertension and hypokalemia)
Ecabet
Rebamipide

Increase Prostanglandins production in stomach

Question 17

Antacids

Answer 17

prompt pain relief

Systemic antacids -
sodium salts (sodium bicarbonate- carbon dioxide produce could lead to distension or perforation of stomach and sodium citrate) - fastest antacids
SE- hypertension and heart disease

calcium salts ( calcium carbonate or bicarbonate) - antacids of choice in renal failure or osteoporosis
SE- maximum rebound acid secretion, milk alkali syndrome

Non systemic antacids -
Al salts - slow acting, reduce GIT motility
Mg salts - fast acting , increase GIT motility

Question 18

Ulcer protectives

Answer 18

polymerise in acidic pH in stomach and then precipitate or cover the ulcer

Sucralfate - sucrose aluminium sulfate
avoid with antacids (gap of 30 mins) food (gap of 60 mins), drugs like phenytoin and Ranitidine (gap of 120 mins)

colloid bismuth salts (subcitrate and subsalicylate)
protective for ulcer, PG synthesis, antibacterial effect on Pylori - treatment of H pylori and travellers diarrhoea
SE- black tongue/feces, osteoporosis

Question 19

Antibiotics against H Pylori

Answer 19

causes peptic ulcer, GERD, maltoma

Clarithromycin
Amoxicillin
Metronidazole (Timidazole, Ordinazole)
Tetracycline
Levofloxacin

new- Rifaximin, Furazolidone

Question 20

Guidelines for treatment of H Pylori

Answer 20

1. give atleast 2 or more antibiotics as single may lead to resistance
2. add PPI > H2 blocker (decreased HCl increases effectiveness of antibiotics)
3. duration of therapy - 10 to 14 days

Question 21

Anti H Pylori regimens

Answer 21

Triple therapy (PCM) - PPI + Clarithromycin+ Metronidazole - 14 days

Triple therapy (PCA) - PPI + Clarithromycin+ Amoxicillin - 14 days

DOC in India - PPI + Bismuth salt + Metronidazole+ Tetracycline - 14 days

Question 22

miscellaneous drugs

Answer 22

Simethicone, Dimethicone - defaming agent- burst air bubbles in GIT - used for flatulence and burps

Alginic acid - makes neutral layer over acid- used for GERD