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Flashcards in GERD & PUD Deck (105):
0

What's GERD?

GERD is a condition in which the stomach contents leak backwards into the esophagus

1

What xterizes GERD?

Lower esophageal sphincter (LES) pressure or muscle tone is reduced (or transiently relaxes)

And allows the BACKFLOW of the stomach contents

2

List typical sx of GERD?

Heartburn

Hypersalivation

Regurgitation

Acid taste in mouth

3

List alarm conditions in which patients require further testing

Chest pain, dysphagia

4

What's the reason behind the recent caution to chronic acid suppression from H2RAs and PPIs?

Concern about

Risk of GI infections (most commonly caused by C.difficile)
And
Increased risk of nosocomial pneumonia in hospitalized pts

5

What other factors result in caution to chronic use of PPIs?

Increased risk of osteoporosis and fractures with long-term use

6

While there's a caution with the use of H2RAs in the elderly per Beers Criteria, which one of them is an absolute C/I in the elderly?

Cimetidine (due to drug-drug int, ADRs)

7

What should pts be aware of, especially the elderly, if H2RAs are overdosed?

Risk of worsening:

Dementia

Delirium/confusion

8

T/F? H2RAs are NOT dosed adjusted for renal impairment?

False!

They are dose adjusted in renal impairment

9

List recommended non-pharmacologic (lifestyle) tx

Avoid foods that may reduce LES pressure e.g. Spicy foods, nicotine, caffeine, alcohol, fatty foods, citrus, chocolate

Smaller portions and eat mor frequently

Weight loss - best evidence in improvement

Don't eat b4 sleeping (last meal should be 2-3 hrs b4 bedtime)

Elevate head of bed 6-8" (with wedges, NOT pillows)

Avoid tight-fitting clothing

10

List agents used in GERD pharmacologic therapy

Antacid

Histamine (H2) Receptor Antagonists (H2RAs)

Proton Pump Inhibitors (PPIs)

Cytoprotective agents

11

MOA of antacids?

Work by neutralizing gastric acid (producing salt and water), thus increasing gastric PH.

They provide relief within mins as antacids don't req systemic absorption

12

List drugs under antacids

Calcium (Tums)

Magnesium (Phillips Milk of Magnesia (MOM))

Mg + (Al or Ca) (Maalox, Mylanta)

Mag-Al-Simethicone (anti-gas) (Maalox, Max, Mylanta Max Strength)

13

Brand name of Calcium (antacid)?

Tums

14

Brand name of Magnesium (antacid)?

Phillips Milk of Magnesia (MOM)

15

Brand name of Magnesium + Aluminum/Calcium (antacid)?

Maalox

Mylanta

16

Brand name of Mg-Al-Simethicone (antacid)?

Maalox Max

Mylanta Max Strength

17

What's the drug of choice during pregnancy?

Antacids

18

Reduced absorption due to chelation is seen in antacid +?

Quinolones and Tetracyclines (Doxycycline and Minocyclines are of less clinical concerns)

19

How do u separate antacids from antibiotics and Itraconazole, Ketoconazole and iron

Use antacids 2hrs B4

And

4-8 hrs after

20

What antibiotics are of less concern wrt to chelation of antacids?

Doxycycline and Minocycline

21

Antacids have a quick onset and quick offset? T/F?

True

They usually only last about 1-2 hrs

22

If a pt has kidney dx, which antacid can they use?

Tums (calcium) only

Avoid Mg and Al

23

If a pt using tums experiences constipation, what's most likely the active ingredient in it?

Al

T4 d/c Al pdts

24

If a pt using tums experiences loose stools, what's most likely the active ingredient in it?

Mg-containing pdts

(Use Tums - contains Ca only)

25

MOA of Histamine H2 Receptor Antagonists (H2RAs)?

H2RAs reversible inhibits the H2 receptors in the gastric parietal cells, thus reducing gastric acid secretion

26

List H2RAs agents

Famotidine (Pepcid AC; AC Max strength)

Ranitidine (Zantac)

Pepcid Complete (Ca Carbonate, Magnesium hydroxide, famotidine)

Nizatidine (Axid)

Cimetidine (Tagamet; HB 200)

27

How are ALL H2RAs agents dosed?

Mild heartburn - PRN

Documented GERD - Twice daily for up to 12 weeks

28

What's the brand name of famotidine? (H2RAs)

Pepcid AC; AC Max Strength

29

What's the brand name of calcium carbonate, magnesium hydroxide, famotidine? (H2RAs)

Pepcid Complete

30

What's the brand name of Ranitidine? (H2RAs)

Zantac

31

What's the dosing and brand name of Famotidine OTC? (H2RAs)

Pepcid AC 10, 20mg - Max Strength

32

What's the dosing and brand name of Famotidine Rx? (H2RAs)

Famotidine Rx

20, 40mg

33

What's the dosing of Ranitidine OTC? (H2RAs)

75, 150mg

34

What's the dosing of Ranitidine Rx? (H2RAs)

300mg

35

Warning associated with H2RAs use?

Risk of worsening dementia and confusion

36

Which H2RAs agent is to be avoided completely in elderly?

Cimetidine

Due to drug interactions and ADRs (CNS effects, gynecomastia, impotence)

37

SEs from H2RAs use?

Risk of GI infections

Risk of pneumonia in hospitalized pts

38

H2RAs and renal impairment?

H2RAs must be dose-adjusted in renal impairment (50% of dose)

39

What can reduce absorption of H2RAs?

Itraconazole

Ketoconazole

Calcium carbonate

Iron

40

Is cimetidine a CYP 3A4 substrate, inducer, inhibitor?

CYP 3A4 inhibitor

41

MOA of Proton Pump Inhibitors (PPIs)?

Irreversibly binds to gastric H+/K+ adenosine Triphosphate (ATPase) pump in parietal cells

42

Where do PPIs work?

They block FIINAL step in acid production

43

How are ALL PPIs used?

Used daily, 30mins B4 breakfast

OR

BID (2nd dose b4 dinner)

44

Dosing of PPIs for treating duodenal or gastric ulcers caused by H. Pylori?

BID

45

List PPIs agents

Omeprazole (Prilosec OTC, Prilosec)

Omeprazole/Sodium Bicarbonate (Zegerid, Zegerid OTC)

Pantoprazole (Protonix)

Lansoprazole (Prevacid; SoluTab; 24H-OTC)

Esomeprazole (Nexium)

Rabeprazole (AcipHex)

46

What's the brand name of Omeprazole? PPIs

Prilosec OTC

Prilosec

47

What's the brand name of Omeprazole/Sodium Bicarbonate? PPIs

Zegerid

Zegerid OTC

48

What's the brand name of Prontoprazole? PPIs

Protonix

49

What's the brand name of Lansoprazole? PPIs

Prevacid,

Prevacid SoluTab

Prevacid 24H-OTC

50

What's the brand name of Esomeprazole? PPIs

Nexium

51

What's the brand name of Rabeprazole? PPIs

AcipHex

52

Which PPIs is on record to avoid use with Clopidogrel?

Omeprazole and Esomeprazole

53

Which supplements should be used with PPIs if they are used long-term?

Calcium (Ca citrate preferred) and Vit. D

54

How soon should u contact the dr if using the PPIs without any relief?

14 days and heartburn persists

55

List Cytoprotective Agents used in GERD.

Misoprostol (Cytotec)

Sucralfate (Carafate)

56

SE of Misoprostol (Cytoprotective agent used in GERD)?

Diarrhea

Abdominal pain

57

Pregnancy category of Misoprostol (Cytoprotective agent used in GERD)?

X

58

Howz Sucralfate used?

QID B4 meals and QHS

59

SE of Sucralfate (Cytoprotective agent used in GERD)?

Comstipation

60

MOA of Metoclopramide?

Dopamine antagonist

61

Brand name of Metoclopramide?

Reglan

62

What's the caution with using Metoclopramide (Reglan) in elderly?

CNS SE are dose related and more common in elderly

63

When's Metoclopramide's use CI?

Parkinson's dx (Metoclopramide is a dopamine antagonist)

64

Metoclopramide (Reglan) dose in renal impairment?

2.5-5mg four times a day

65

Which PPIs is available in IV formulation?

Nexium (Esomeprazole)

Protonix (Pantoprazole)

66

What can PPIs increase the risk of?

Bone fracture

C. difficle infection

Pneumonia in hospitalized pts

67

Start of PUD (peptic ulcer dx)

PUD

68

List 3 common causes of PUD

H. pylori-positive ulcers

NSAIDs-induced ulcers

Stress ulcers in presence of critical illness & in mechanically-ventilated pts

69

What's Helicobacter Pylori?

Spiral-shaped

Gram-negative

70

What's the primary sx of PUD?

Gastric pain (associated with a burning or gnawing sensation and may awaken a pt at night)

71

What type of PUD is typically caused by H. pylori?

Duodenal PUD

72

What type of PUD is typically caused by NSAIDs?

Gastric ulcers

73

What generally lessens the pain associated with duodenal ulcer (primarily caused by H. pylori)?

Eating

74

What generally worsens the pain associated with gastric ulcer (primarily caused by NSAIDs)?

Eating

75

T/F: Eating LESSENS pain of duodenal ulcers and WORSENS the pain of gastric ulcers?

T

76

List other sx of PUD

Heartburn

Belching

Bloating

Nausea

Anorexia

77

What's the concern with untreated H. pylori?

Can lead to cancer

78

How soon b4 urea breath test (UTB - test for H. pylori) should H2RAs, PPIs, Bismuth and Antibiotics be d/c?

H2RAs, PPIs - 1 to 2 wks B4 UTB

Bismuth, Antibiotics - 4 wks B4 UTB

79

How soon b4 Fecal antigen test (test for H. pylori in stool) should H2RAs, PPIs, Bismuth and Antibiotics be d/c?

H2RAs, PPIs, Bismuth and Antibiotics - at least 2 - 4 wks

80

What's the recommended therapy for PUD?

Triple therapy for 14 days

81

What constitutes triple therapy (recommended tx for PUD)?

Anti-secretory agent (preferably a PPI)

+

2 antibiotics (Clarithromycin and Amoxicillin)

82

If the pt has a penicillin allergy, what can be used in place of Amoxicillin?

Metronidazole

83

What's the alternative to triple therapy? When would u use this?

Quadruple therapy

If pt has used a Macrolide or metronidazole in the past

OR

If local failure rates are known to be high

84

What constitutes quadruple therapy (alternative tx for PUD)?

PPI + Bismuth + Metronidazole + Tetracycline for 10-14 days

Can use Helidac or Pylera

85

Whats a second alternative to treating PUD?

Sequential therapy:

PPI + Amoxicillin x 5 days, followed by

PPI + Clarithromycin + Tinidazole x 5 days

86

Are drug substitutions in H. pylori permitted in H.pylori education?

No

87

List 1st-line H.pylori regimens

Triple Drug Therapy

PPI BID (or Esomeprazole 40mg daily) + Amoxicillin 1,000mg BID + Clarithromycin 500mg BID x 14 days

88

Alternative if pt has penicillin or Macrolide allergy?

Replace Amoxicillin or Clarithromycin with Metronidazole 500mg BID

89

Dosing in Quadruple therapy in H.pylori?

PPI bid (or Esomeprazole daily) + Bismuth subsalicylate 525mg QID + Metronidazole 250mg QID + Tetracycline 500mg QID x 10-14 days

90

If a pt uses alcohol, which med in the quadruple therapy used in H.pylori, what med must be substituted?

Metronidazole

91

If a pt is pregnant, which med in the quadruple therapy used in H.pylori, must be substituted?

Tetracycline

92

If a pt has Salicylate allergy, which med in the quadruple therapy used in H.pylori must be substituted?

Bismuth subsalicylate

93

If a pt is < 8yrs, which med in the quadruple therapy used in H.pylori, must be substituted?

Tetracycline

94

If a pt can't tolerate PPI, which med in the quadruple therapy used in H.pylori must be substituted?

Substitue H2RA e.g, Ranitidine 150mg BID, Famotidine 40mg daily, Nizatidine 300 mg/d

95

List combo pdts used in H. pylori

Pervpac

Pylera

Helidac

96

What's the ingredients in Prevpac? Dosing?

Lansoprazole/Amoxicillin/Clarithromycin all in 1 blister pack

BID x 14 days

97

What's the ingredients in Pylera? Dosing?

Bismuth subcitrate potassium/Metronidazole/Tetracycline in 1 capsule

Take 3 capsule QID x 10 days

+

PPI BID (Esomeprazole BID) x 10 days

98

What's the ingredients in Helidac? Dosing?

Bismuth subsalicylate/Metronidazole/Tetracycline x 14 days

+

H2RA x 28 days

99

T/F? Clarithromycin is a strong inhibitor?

T

100

Effect of metronidazole on warfarin?

May increase INR

101

Risk factors for NSAID-induced ulcers?

Age > 65 yrs

Previous ulcers

High-dose or chronic NSAID use

Concomitant use of steroids, anticoagulants, SSRIs or SNRIs

102

What may be used in high-risk pts (NSAID-induced ulcer)?

COX-2 selective agent e.g. Celecoxib, meloxicam, nabumetone and etodolac

103

In what pt grps are NSAIDs used with caution?

Cardiovascular and Renal dx

104

If possible, avoid non-selective NSAIDs and Celecoxib in what pt grps?

In pts with both high GI and CV risk

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