Flashcards in GERD & PUD Deck (105):
GERD is a condition in which the stomach contents leak backwards into the esophagus
What xterizes GERD?
Lower esophageal sphincter (LES) pressure or muscle tone is reduced (or transiently relaxes)
And allows the BACKFLOW of the stomach contents
List typical sx of GERD?
Acid taste in mouth
List alarm conditions in which patients require further testing
Chest pain, dysphagia
What's the reason behind the recent caution to chronic acid suppression from H2RAs and PPIs?
Risk of GI infections (most commonly caused by C.difficile)
Increased risk of nosocomial pneumonia in hospitalized pts
What other factors result in caution to chronic use of PPIs?
Increased risk of osteoporosis and fractures with long-term use
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)
What should pts be aware of, especially the elderly, if H2RAs are overdosed?
Risk of worsening:
T/F? H2RAs are NOT dosed adjusted for renal impairment?
They are dose adjusted in renal impairment
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
List agents used in GERD pharmacologic therapy
Histamine (H2) Receptor Antagonists (H2RAs)
Proton Pump Inhibitors (PPIs)
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
List drugs under antacids
Magnesium (Phillips Milk of Magnesia (MOM))
Mg + (Al or Ca) (Maalox, Mylanta)
Mag-Al-Simethicone (anti-gas) (Maalox, Max, Mylanta Max Strength)
Brand name of Calcium (antacid)?
Brand name of Magnesium (antacid)?
Phillips Milk of Magnesia (MOM)
Brand name of Magnesium + Aluminum/Calcium (antacid)?
Brand name of Mg-Al-Simethicone (antacid)?
Mylanta Max Strength
What's the drug of choice during pregnancy?
Reduced absorption due to chelation is seen in antacid +?
Quinolones and Tetracyclines (Doxycycline and Minocyclines are of less clinical concerns)
How do u separate antacids from antibiotics and Itraconazole, Ketoconazole and iron
Use antacids 2hrs B4
4-8 hrs after
What antibiotics are of less concern wrt to chelation of antacids?
Doxycycline and Minocycline
Antacids have a quick onset and quick offset? T/F?
They usually only last about 1-2 hrs
If a pt has kidney dx, which antacid can they use?
Tums (calcium) only
Avoid Mg and Al
If a pt using tums experiences constipation, what's most likely the active ingredient in it?
T4 d/c Al pdts
If a pt using tums experiences loose stools, what's most likely the active ingredient in it?
(Use Tums - contains Ca only)
MOA of Histamine H2 Receptor Antagonists (H2RAs)?
H2RAs reversible inhibits the H2 receptors in the gastric parietal cells, thus reducing gastric acid secretion
List H2RAs agents
Famotidine (Pepcid AC; AC Max strength)
Pepcid Complete (Ca Carbonate, Magnesium hydroxide, famotidine)
Cimetidine (Tagamet; HB 200)
How are ALL H2RAs agents dosed?
Mild heartburn - PRN
Documented GERD - Twice daily for up to 12 weeks
What's the brand name of famotidine? (H2RAs)
Pepcid AC; AC Max Strength
What's the brand name of calcium carbonate, magnesium hydroxide, famotidine? (H2RAs)
What's the brand name of Ranitidine? (H2RAs)
What's the dosing and brand name of Famotidine OTC? (H2RAs)
Pepcid AC 10, 20mg - Max Strength
What's the dosing and brand name of Famotidine Rx? (H2RAs)
What's the dosing of Ranitidine OTC? (H2RAs)
What's the dosing of Ranitidine Rx? (H2RAs)
Warning associated with H2RAs use?
Risk of worsening dementia and confusion
Which H2RAs agent is to be avoided completely in elderly?
Due to drug interactions and ADRs (CNS effects, gynecomastia, impotence)
SEs from H2RAs use?
Risk of GI infections
Risk of pneumonia in hospitalized pts
H2RAs and renal impairment?
H2RAs must be dose-adjusted in renal impairment (50% of dose)
What can reduce absorption of H2RAs?
Is cimetidine a CYP 3A4 substrate, inducer, inhibitor?
CYP 3A4 inhibitor
MOA of Proton Pump Inhibitors (PPIs)?
Irreversibly binds to gastric H+/K+ adenosine Triphosphate (ATPase) pump in parietal cells
Where do PPIs work?
They block FIINAL step in acid production
How are ALL PPIs used?
Used daily, 30mins B4 breakfast
BID (2nd dose b4 dinner)
Dosing of PPIs for treating duodenal or gastric ulcers caused by H. Pylori?
List PPIs agents
Omeprazole (Prilosec OTC, Prilosec)
Omeprazole/Sodium Bicarbonate (Zegerid, Zegerid OTC)
Lansoprazole (Prevacid; SoluTab; 24H-OTC)
What's the brand name of Omeprazole? PPIs
What's the brand name of Omeprazole/Sodium Bicarbonate? PPIs
What's the brand name of Prontoprazole? PPIs
What's the brand name of Lansoprazole? PPIs
What's the brand name of Esomeprazole? PPIs
What's the brand name of Rabeprazole? PPIs
Which PPIs is on record to avoid use with Clopidogrel?
Omeprazole and Esomeprazole
Which supplements should be used with PPIs if they are used long-term?
Calcium (Ca citrate preferred) and Vit. D
How soon should u contact the dr if using the PPIs without any relief?
14 days and heartburn persists
List Cytoprotective Agents used in GERD.
SE of Misoprostol (Cytoprotective agent used in GERD)?
Pregnancy category of Misoprostol (Cytoprotective agent used in GERD)?
Howz Sucralfate used?
QID B4 meals and QHS
SE of Sucralfate (Cytoprotective agent used in GERD)?
MOA of Metoclopramide?
Brand name of Metoclopramide?
What's the caution with using Metoclopramide (Reglan) in elderly?
CNS SE are dose related and more common in elderly
When's Metoclopramide's use CI?
Parkinson's dx (Metoclopramide is a dopamine antagonist)
Metoclopramide (Reglan) dose in renal impairment?
2.5-5mg four times a day
Which PPIs is available in IV formulation?
What can PPIs increase the risk of?
C. difficle infection
Pneumonia in hospitalized pts
Start of PUD (peptic ulcer dx)
List 3 common causes of PUD
H. pylori-positive ulcers
Stress ulcers in presence of critical illness & in mechanically-ventilated pts
What's Helicobacter Pylori?
What's the primary sx of PUD?
Gastric pain (associated with a burning or gnawing sensation and may awaken a pt at night)
What type of PUD is typically caused by H. pylori?
What type of PUD is typically caused by NSAIDs?
What generally lessens the pain associated with duodenal ulcer (primarily caused by H. pylori)?
What generally worsens the pain associated with gastric ulcer (primarily caused by NSAIDs)?
T/F: Eating LESSENS pain of duodenal ulcers and WORSENS the pain of gastric ulcers?
List other sx of PUD
What's the concern with untreated H. pylori?
Can lead to cancer
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
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
What's the recommended therapy for PUD?
Triple therapy for 14 days
What constitutes triple therapy (recommended tx for PUD)?
Anti-secretory agent (preferably a PPI)
2 antibiotics (Clarithromycin and Amoxicillin)
If the pt has a penicillin allergy, what can be used in place of Amoxicillin?
What's the alternative to triple therapy? When would u use this?
If pt has used a Macrolide or metronidazole in the past
If local failure rates are known to be high
What constitutes quadruple therapy (alternative tx for PUD)?
PPI + Bismuth + Metronidazole + Tetracycline for 10-14 days
Can use Helidac or Pylera
Whats a second alternative to treating PUD?
PPI + Amoxicillin x 5 days, followed by
PPI + Clarithromycin + Tinidazole x 5 days
Are drug substitutions in H. pylori permitted in H.pylori education?
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
Alternative if pt has penicillin or Macrolide allergy?
Replace Amoxicillin or Clarithromycin with Metronidazole 500mg BID
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
If a pt uses alcohol, which med in the quadruple therapy used in H.pylori, what med must be substituted?
If a pt is pregnant, which med in the quadruple therapy used in H.pylori, must be substituted?
If a pt has Salicylate allergy, which med in the quadruple therapy used in H.pylori must be substituted?
If a pt is < 8yrs, which med in the quadruple therapy used in H.pylori, must be substituted?
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
List combo pdts used in H. pylori
What's the ingredients in Prevpac? Dosing?
Lansoprazole/Amoxicillin/Clarithromycin all in 1 blister pack
BID x 14 days
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
What's the ingredients in Helidac? Dosing?
Bismuth subsalicylate/Metronidazole/Tetracycline x 14 days
H2RA x 28 days
T/F? Clarithromycin is a strong inhibitor?
Effect of metronidazole on warfarin?
May increase INR
Risk factors for NSAID-induced ulcers?
Age > 65 yrs
High-dose or chronic NSAID use
Concomitant use of steroids, anticoagulants, SSRIs or SNRIs
What may be used in high-risk pts (NSAID-induced ulcer)?
COX-2 selective agent e.g. Celecoxib, meloxicam, nabumetone and etodolac
In what pt grps are NSAIDs used with caution?
Cardiovascular and Renal dx