Chapter 71: GERD & PUD Flashcards
(91 cards)
1
Q
Acidic gastric contents are normally prevented from backflow into the esophagus by a protective ring of muscle fibers called the ____
A
lower esophageal sphincter (LES)
2
Q
Patients with GERD have ____ LES pressure.
A
Reduced
3
Q
What are the typical GERD symptoms?
A
- Heartburn
- Hypersalvation
- Regurgitation of acidic content
4
Q
How many times per week must symptoms of GERD occur in order to be diagnosed?
A
> = 2 times per week
5
Q
Patients who are refractory to GERD treatment may benefit from?
A
24-hour esophageal pH monitoring
6
Q
Key drugs that can worsen GERD symptoms?
A
- ASA/NSAIDs,
- Dabigatran,
- Bisphosphonates,
- Fish Oils,
- Estrogen products,
- Iron supplements,
- NRTs,
- Steroids,
- Tetracyclines
7
Q
When should a patient with GERD be referred for further evaluation?
A
If they do not respond to lifestyle modifications and/or two weeks of self-treatment with OTC products, or if alarm symptoms are present
8
Q
How can infrequent heartburn be treated (< 2 times per week)?
A
PRN OTC antacids or H2RAs
9
Q
What is the initial treatment of choice for GERD?
A
8-week course of a PPI once daily
10
Q
What is used for maintenance treatment if symptoms return after the initial 8 week treatment for GERD?
A
PPI at the lowest effective dose
11
Q
Antacid MOA?
A
Neutralize gastric acid which increases gastric pH
12
Q
What is the onset and duration of action for antacids?
A
Onset: minutes
Duration: 30-60 min
13
Q
Calcium carbonate brand name?
A
Tums
14
Q
Calcium carbonate + magnesium brand name?
A
Mylanta Supreme
15
Q
Calcium carbonate + simethicone brand name?
A
Maalox Advanced Max Strength
16
Q
Magnesium hydroxide brand name?
A
Milk of Magnesia
17
Q
Magnesium hydroxide + aluminum + simethicone brand name?
A
Mylanta Maximum Strength
18
Q
Sodium bicarbonate/ASA/citric acid brand name?
A
Alka-Seltzer
19
Q
Antacid warning?
A
Aluminum and magnesium can accumulate with severe renal dysfunction
20
Q
Side effect of calcium?
A
Constipation
21
Q
Side effect of aluminum?
A
Constipation
22
Q
Side effect of magnesium?
A
Loose stools
23
Q
Which antacids may be preferred in pregnancy?
A
Calcium-containing antacids
24
Q
MOA of H2RAs?
A
Reversibly inhibits H2 receptors on gastric parietal cells, which decreases gastric acid secretion
25
Famotidine brand name?
Pepcid AC, Zantac 360
26
Which two H2RAs come as an injection?
Famotidine
27
What warning does H2RA come with?
Confusion, usually reversible (risk factors: elderly, severely ill, renal impairment)
28
What are side effects of cimetidine at high doses?
Gynecomastia, impotence
29
You must decrease the dose of famotidine when CrCl < ___?
60 mL/min
30
Which H2RA should be avoided due to drug interactions and side effects?
Cimetidine
31
MOA of PPIs?
Irreversibly bind to the gastric H+/K+-ATPase pump in the parietal cells. This shuts down the proton pump and blocks gastric acid secretion
32
Esomeprazole brand name?
Nexium
33
Lansoprazole brand name?
Prevacid, Prevacid Solutabs
34
Omeprazole brand name?
Prilosec
35
Dexlansoprazole brand name?
Dexilant
36
Pantoprazole brand name?
Protonix
37
Which PPIs should be taken before breakfast?
Esomeprazole, lansoprazole and omeprazole
38
Esomeprazole should be taken how far in advance before breakfast?
at least 60 minutes
39
Which PPI can be taken without regard to meals?
Dexlansoprazole
40
Pantoprazole oral suspension should be taken how far in regards to a meal?
30 minutes before
41
Which 2 PPIs come as an injection?
Esomeprazole and pantoprazole
42
Esomeprazole + Naproxen brand name?
Vimovo
43
PPIs can cause what vitamin deficiency with prolonged use (>= 2 years)?
Vitamin B12
44
What are other warnings of PPIs besides B12 deficiency?
* C-diff-associated diarrhea,
* hypomagnesemia,
* Vitamin B!2 deficiency
* osteoporosis-related bone fractures with high doses or long-term use (>= 1 year)
45
Which PPIs should not be used with Plavix due to diminishing therapeutic effects?
Omeprazole and esomeprazole
46
Which PPI capsules can be opened?
Dexlansoprazole, esomeprazole, lansoprazole, omeprazole and rabeprazole (all except pantoprazole)
47
Which H2RAs are OTC?
Cimetidine, famotidine
48
Which PPIs are OTC?
Esomeprazole, lansoprazole, omeprazole
49
Which PPIs are ODT?
Lansoprazole, omeprazole
50
Which H2RAs come as oral solutions/suspensions?
Cimetidine, famotidine
51
Which PPIs come as packets for suspensions?
Esomeprazole, Omeprazole, Pantoprazole,
52
Which PPIs are available in injection?
Esomeprazole and Pantoprazole
53
Metoclopramide drug class
Dopamine antagonist
54
Metoclopramide MOA
accelerated gastric emptying and increased LES tone
55
When should metoclopramide be taken?
Before meals and at bedtime
56
Dose of metoclopramide should be decreased by ___% in CrCl < ___ mL/min to avoid CNS/EPS side effects
50%
< 40
57
Metoclopramide boxed warning
Tardive dyskinesia
58
Metoclopramide should be avoided in patients with
Parkinson disease
59
Drugs that should be avoided completely with PPIs & H2RAs
* DR formulation of risedronate (Atelvia)
* Rilpivirine
* Epclusa
60
Key drugs that require an acidic gut and absorption will decrease by antacids, H2RAs and PPIs
Antiretrovirals: Rilpivirine (NNRTI), atazanavir (PI)
Antivirals: ledipasvir, velpatasvir/sofosbuvir
Azole antifungals: itraconazole, ketoconazole, posaconazole oral suspension
Cephalosporins (oral): cefpodoxime, cefuroxime
Iron products
Mesalamine
Risedronate DR
TKI: dasatanib, erlotinib, pazopanib
61
Key oral drugs/drug classes that antacids bind
Antiretrovirals (INSTIs): bictegravir, dolutegravir, elvitegravir
Bisphosphonates
Isoniazid
Levothyroxine
Mycophenolate
Quinolones
Sotalol
Steroids (esp budesonide)
Tetracyclines
62
H2RAs should be used with caution with
CNS depressants d/t risk of additive delirium, dementia, and cognitive impairment. Use lower doses in patients with renal impairment
63
Cimetidine is a moderate ____ of CYP 2C19
Inhibitor
64
All PPIs inhibit which CYP enzyme?
2C19
65
Metoclopramide should not be used in combination with which drug class?
Antipsychotic drugs
66
What are the 3 most common causes of PUD?
H.pylori, NSAID-induced ulcers and stress ulcers which occur in critically ill and mechanically ventilated patients
67
Primary symptom of PUD and other symptoms
Primary symptom is dyspepsia, a gastric pain which can feel like a gnawing or burning sensation in the middle or upper stomach
## Footnote
Other sx: heartburn, belching, bloating, cramping, nausea and anorexia
68
If the ulcer is duodenal (usually caused by H.pylori) pain is typically worse when?
2-3 hours after eating (when the stomach is empty)
69
What can help the pain from a duodenal peptic ulcer?
Eating food or taking antacids lessen the pain
70
If the ulcer is gastric (usually caused by NSAIDs) pain is typically worse when?
After eating
71
What is the common, non-invasive diagnostic test used to detect H.pylori?
Urea breath test (UBT)
72
Which drugs should be d/c prior to UBT test and fecal antigen test to detect H.pylori and how long before the tests should they be d/c?
PPIs, bismuth, and antibiotics d/c 2 weeks prior to avoid false negatives
73
Which type of therapy is first-line for H.pylori treatment?
Quadruple therapy
74
The use of triple-therapy first line for H.pylori treatments is only recommended if:
Clarithromycin resistance rates are low and the patient has no previous hx of taking a macrolide antibiotic
75
Which drugs are included in quadruple therapy for H.pylori treatment?
Bismuth subsalicylate 300 mg QID
Metronidazole 250-500 mg QID
Tetracycline 500 mg QID
PPI BID (or esomeprazole 40 mg daily)
## Footnote
or use a 3-in-1 combination product + PPI: Pylera (Bismuth subcitrate potassium 420 mg + metronidazole 375 mg + tetracycline 375 mg) QID + PPI BID
76
Which drug should not be used in the quadruple therapy for H.pylori treatment if patient has hx of alcohol use?
Metronidazole
77
Which drug should not be used in the quadruple therapy for H.pylori treatment if patient is pregnant or if the pt is a child?
Tetracycline
78
How long should quadruple therapy be used for H.pylori treatment?
10-14 days
79
Which drugs are included in triple therapy for H.pylori treatment?
Amoxicillin 1000 mg BID
Clarithromycin 500 mg BID
PPI BID (or esomeprazole 40 mg daily)
## Footnote
or use a 3-in-1 combination product + PPI: Prevpac (amoxicillin + clarithromycin + lansoprazole)
80
If a patient has a PCN allergy, which drug should be changed and which drug should it be changed to in triple therapy?
Replace amoxicillin with metronidazole
81
All NSAIDs should be used with caution in:
Any person with CV or renal disease (since can elevate BP and decrease renal blood flow)
82
NSAIDs with selective inhibition of COX2 (e.g., celecoxib) have decreased ___ risk but increased ___ risk compared to non-selective NSAIDs
Decreased GI risk
Increased CV risk
83
NSAIDs that approach the selectivity of celecoxib are
Meloxicam, nabumetone, diclofenac, and etodolac
84
Which combination product reduces the risk of NSAID-induced ulcers?
Naproxen/esomeprazole (Vimovo)
85
Which drug is approved for secondary prevention of CV and cerebrovascular events in patients at risk for aspirin-associated ulcers?
Aspirin/omeprazole - Yosprala
86
If an ulcer develops from NSAID use, what should be used as treatment?
PPI for 8 weeks
87
Drug class for misoprostol
Prostaglandin E1 analog
88
When should sucralfate be taken?
Before meals on an empty stomach
89
Side effects of misoprostol
Diarrhea, abdominal pain
90
Side effect of sucralfate
Constipation
91
Risk factors for NSAID-induced ulcers
Age > 60 yo
Hx of PUD
High-dose NSAIDs
Using > 1 NSAID (e.g., NSAID + ASA)
Concomitant use of anticoagulants, steroids, SSRIs or SNRIs
