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Therapeutics II > Block 1 - GERD > Flashcards

Block 1 - GERD Flashcards

1
Q

What is GERD?

A

Sx from refluxed stomach contents into esophagus, oral cavity, for lungs

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2
Q

What are the risk factors of GERD?

A
  1. Smoking
  2. Alcohol
  3. Trigger in food or meds
  4. Respiratory disease
  5. Obesity
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3
Q

What are the food trigers for GERD?

A

Spicy foods, acidic foods (tomato), coffee, alcohol

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4
Q

What are the med triggers for GERD?

A

NSAIDs, ASA, Iron, bisphosphonates

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5
Q

What are the typical sx of GERD?

A
  1. Heartburn
  2. Regurgitation
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6
Q

What are atypical sx of GERD?

A
  1. Dyspepsia
  2. Epigastric pain
  3. N
  4. Belching
  5. Bloating
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7
Q

What are alarming sx of GERD?

A
  1. Dysphagia
  2. Odynophagia
  3. GI bleeding
  4. Weigh loss
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8
Q

What are Extraesophageal sx of GERD?

A
  1. Chronic cough
  2. Asthma
  3. Chronic laryngitis
  4. Airway sx
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9
Q

What are the types of GERD tissue injuries?

A
  1. Esophagitis
  2. Barretts esophagus
  3. Esophageal strictures
  4. Esophageal adenocarcinoma
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10
Q

What are the dangers of Barretts esophagus?

A

Can be a precursor to cancer

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11
Q

How can we diagnos GERD?

A
  1. Clinical hx for typical sx
  2. Tests: not respondant to thearpy or have alarm sx
  3. Endoscopy is preferred
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12
Q

What are the goals of GERD treatments?

A
  1. Reduce or eliminate symptoms
  2. Decrease frequency and duration of GERD
  3. Promote healing of injured mucosa
  4. Prevent complications
  5. Improve quality of life
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13
Q

What are the considered treatments of GERD?

A
  1. Lifestyle modifications
  2. Patient-directed therapy with antacids, nonprescription H2RAs and/or nonprescription PPIs
  3. Pharmacologic treatment with prescription strength acid suppression therapy
  4. Prokinetics
  5. Surgery
  6. Endoscopic therapies
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14
Q

What are the lifestyle mods for GERD?

A
  1. Weight loss
  2. Head elevation 6-8 in
  3. Smaller meals
  4. Wait 3 hr after eating to sleep
  5. Avoid triggers
  6. Smoking cessation
  7. Avoid tight fitting clothes
  8. Avoid alcohol
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15
Q

What are the antacids?

A
  1. Calcium
  2. Aluminum
  3. Magnesium
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16
Q

What are the H2RAs?

A

Cimetidine
Famotidine
Nizatadine
Ranitidine*

Ranitidine no longer on the market

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17
Q

What are the PPIs?

A

Dexlansoprazole, lansoprazole
Esomeprazole, omeprazole
Pantoprazole
Rabeprazole

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18
Q

What are the prokinetics?

A
  1. Metoclopramide
  2. Bethanechol
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19
Q

What are the exclusions of self care?

A
  1. Heartburn 3 months and nocturnal
  2. OTC x 2 weeks w/ sx
  3. Severe typical and atypical sx
  4. Alarm sx
  5. Extraesophageal sx
  6. Children
  7. > 45YO w/ ne dyspepsia
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20
Q

What is first line tx for acute sx less than 2x weekly?

A

Antacids

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21
Q

What is the MOA of antacids?

A

Neutralize acid and raise intragastic pH to > 4 which decreases activation of pepsinogen and increases LES pressure

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22
Q

What are the formulations of antacids?

A

Capsules, tablets, chewable, suspensions

Aluminum, calcium, magnesium based

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23
Q

What is antacids a good option?

A
  1. Inexpensive
  2. Quick onset
  3. Short DOA
  4. Food increase duration
24
Q

What are the ADRs of antacids?

A
  1. Constipation (aluminum)
  2. Diarrhea (magnesium)
25
Q

What is the antacid coformulation? MOA?

A

Alginic acid (Gaviscon) forms a viscuous layer on top of gastric contents to act as a barrier to reflux

Reduces frequency of episodes

26
Q

How do you does antacids?

A

Hourly to PRN

27
Q

What is the MOA of H2RAs? Indication?

A

Decrease gastric acid secretion and volume by inhibiting histamine on the H2-receptor

Mild-moderate GERD

28
Q

H2RA response is based on what factors?

A
  1. Severity of disease
  2. Dosage regimen used
  3. Duration of therapy
29
Q

What is the H2RA IV?

A

Famotidine

30
Q

What H2RA is inhibited by CYP?

A

Cimetidine (1A2, 2C9, 2D6, 3A4)

31
Q

What is the onset of H2RA?

A

1 hour

32
Q

What is the ADR of H2RA?

A

HA, DZ, constipation, diarrhea, drowsiness

33
Q

Dosing of H2RA?

A

Tolerance can occur if QD, PRN is better

Renal adjustment is required

34
Q

Your patient takes warfarin for AFIB and is interested in adding an H2RA to his home medications for management of GERD symptoms.

Which of the following would be the expected result of selecting cimetidine as his home H2RA?

A. Increased risk of stroke
B. Decreased risk of anticoagulation-related bleeding
C. Supratherapeutic INR
D. No risk of drug-drug interaction here

A

Supratherapeutic INR due to CYP inhibition from cimetidine, therefore, warfarin toxicity will occur due to CYP2C9 inhibition.

35
Q

What is the MOA of PPIs?

A

Suppresses gastric acid secretion by inhibiting the parietal cell H+/K+ ATP pump

36
Q

What is the most effective treatment for acute and chronic GERD?

A

PPIs

37
Q

IV PPIs?

A

Esomeprazole and pantoprazole

38
Q

Administration of PPIs?

A

Administer 30-60 minutes before the first meal

39
Q

ADRs of PPIs?

A

Diarrhea, Constipation, Flatulence

40
Q

What are the major ADRs of PPis?

A
  1. Increased risk for clostridium difficile–associated diarrhea (CDAD)
  2. Fractures
  3. Hypomagnesemia
  4. Interstitial nephritis
  5. Vitamin B12 deficiency
  6. Community acquired pneumonia
41
Q

How do you deprescribe PPIs?

A
  1. Review indication and effectiveness
  2. Assess the balance of benefits and harm
  3. Assess patients values and preferences
  4. Decide whether to continue, reduce, or dc PPI
  5. Deprescribe and monitor
42
Q

What are the indications of continuous PPI?

A
  1. Sever esophagitis (LA, C or D)
  2. Barretts
  3. Hx of GI ulcer bleeding
  4. Chronic NSAIDs with bleeding risk
  5. Zolinger-Ellison syndrome
43
Q

Compare the onset and DOA of GERD treatments?

A
Antacids are fastest
44
Q

How do you treat GERD in elderly patients?

A
  1. More likely to take medications that cause heartburn/dyspepsia
  2. Higher risk of complications
  3. PPIs on Beers list
  4. Determine renal impairment
  5. Identify DDIs
45
Q

What is the recommendation of GERD treatment in Age > 2 years?

A

Children’s formula of calcium carbonate containing antacids

46
Q

What is the recommendation of GERD treatment in Age > 12 years?

A

H2RAs

47
Q

What is the recommendation of GERD treatment in Age > 18 years?

A

PPIs

48
Q

How do you treat GERD durign pregnancy?

A
  1. Lifestyle mod
  2. Calcium and magnesium may be used (not exceeding QD dose)
  3. H2RAs compatible
49
Q

How do you treat GERD during lactation?

A
  1. Aluminum, calcium, or magnesium containing antacids are safe
  2. Cimetidine and famotidine are compatible

Do not use PPIs

50
Q

What is the treatment for refractory GERD?

A
  1. Symptomatic despite optimization of PPI therapy: Twice daily PPI over 12 weeks
  2. Ensure compliance and timing of PPI
  3. Nocturnal acid -> add H2Ra
  4. Endoscopy: if negative, ambulatory reflux monitoring
  5. Interventional approaches
51
Q

How do we screen for Barretts

A

Men who have GERD sx weekly and no response to PPI tx, and have at least 2 of the following factors:
1. Family hx of Barretts or esophageal cancer
2. Causasian
3. Over 50
4. Hx of smoking
5. Abdominal fat

52
Q

58 y/o male with known heartburn controlled with lifestyle modifications. Friends invited him out to local chili cook-off, and he seeks advice on preventing symptoms for the event.

A. Daily PPI
B. Daily H2RA
C. PRN H2RA
D. PRN Antacid
E. Lifestyle Counseling

A

D. PRN antacid or C. PRN H2RA: due to infrequency of sx and a one time event.

53
Q

46 y/o mother of 2 with a new job complains of moderate heartburn symptoms 3-4 times per week

A. Daily PPI
B. Daily H2RA
C. PRN H2RA
D. PRN Antacid
E. Lifestyle Counseling

A

E. Lifestyle counseling: First
PRN H2RA: Moderate sx but temporary due to tolerance. It can be related to her job

54
Q

82 y/o female complains of mild heartburn symptoms 1-2 times per week. Has tried diet and lifestyle modifications but symptoms continue. Seeks medication. PMH: CKD

A. Daily PPI
B. Daily H2RA
C. PRN H2RA
D. PRN Antacid
E. Lifestyle Counseling

A

PRN Antacid: Sx are infrequent, PPI are CI with elderly, H2RA require renal adjustment
Confirm lifestyle modification

55
Q

54 y/o male presents complaining of severe heartburn, pounding in his chest. He appears pale, weak, diaphoretic, short of breath. Seeks medical treatment for ongoing heartburn symptoms. PMH: HTN, HLD

A. Daily PPI
B. Daily H2RA
C. PRN H2RA
D. PRN Antacid
E. Lifestyle Counseling

A

OTC exclusion leads to go to hospital

56
Q

22 y/o male seeks heartburn relief after consuming too many spicy wings and beer at a local pub.

A. Daily PPI
B. Daily H2RA
C. PRN H2RA
D. PRN Antacid
E. Lifestyle Counseling

A

** D. PRN Antacid** is fast acting and doesn’t seem frequent sx
Lifestyle mod

57
Q

34 y/o female seeks relief of frequent, severe GERD symptoms. Started omeprazole OTC 5 days ago with no relief of symptoms. Also taking antacids for breakthrough symptoms.

A. Daily Rx PPI
B. Daily H2RA
C. BID PPI
D. QD PPI + H2RA
E. Lifestyle Counseling

A

A. QD Rx PPI Patient is on a low dose of PPI and is experiencing refractory GERD sx

Lifestyle modifications

Refer to doctor if comes into pharmacy.

Therapeutics II (30 decks)

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