GERD & PUD Flashcards
(29 cards)
What are 9 drugs/drug classes that can worsen GERD symptoms?
- ASA/NSAIDs
- bisphosphonates
- dabigatran
- estrogen products
- fish oil products
- iron supplements
- nicotine replacement therapy
- steroids
- tetracyclines
When should a patient be referred for further evaluation of GERD?
If they do not respond to lifestyle modifications and/or two weeks of self-treatment with OTC products, or if alarm symptoms are present (odynophagia [painful swallowing], dysphagia, frequent N/V, hematemesis, black or bloody stools, unintentional weight loss) -> refer
What is the GERD treatment algorithm from lifestyle modifications to initial drug treatment to maintenance treatment?
Lifestyle modifications
- weight loss
- elevate head of bed
- avoid eating high fat meals within 2-3 hrs of bedtime
- avoid foods/beverages that trigger reflux
Initial drug treatment
- PPI once daily for 8 weeks
- then stop treatment and see if symptoms return
Maintenance treatment
- 1st line: PPI at lowest effective dose
- alternative: H2RA if there is no erosive esophagitis and it relieves symptoms
- NOT metoclopramide or sucralfate
What are the brand names of these drugs:
- calcium carbonate
- calcium + magnesium
- calcium + simethicone
- magnesium hydroxide
- magnesium hydroxide + aluminum + simethicone
- sodium bicarbonate/aspirin/citric acid
calcium carbonate (Tums)
calcium carbonate + magnesium (Mylanta Supreme)
calcium carbonate + simethicone (Maalox Advanced Maximum Strength)
magnesium hydroxide (Milk of Magnesia)
magnesium hydroxide + aluminum + simethicone (Mylanta Maximum Strength)
sodium bicarbonate/aspirin/citric acid (Alka-Seltzer)
Do these drugs cause constipation or diarrhea: calcium, aluminum, magnesium? What antacid is preferred in pregnancy?
calcium: constipation
aluminum: constipation
magnesium: diarrhea
Calcium-containing antacids may be preferred in pregnancy
What is the MOA of H2RAs? When should we use these for GERD? When should you decrease the dose of famotidine? What are 2 side effects of cimetidine? Which H2RA should we avoid due to drug interactions and side effects?
MOA - reversibly inhibit H2 receptors, which decreases gastric acid secretion
Used PRN for infrequent or mild heartburn and can be used as maintenance treatment.
Famotidine (Pepcid AC, Zantac 360) - decrease dose when CrC; < 60mL/min
Cimetidine:
- side effects: gynecomastia, impotence
- AVOID cimetidine due to drug interactions (CYP3A4 inhibitor) and side effects
What is the MOA of PPIs? Which PPIs must be taken before breakfast vs. without regard to meals? What are 5 warnings? Which 2 PPIs are the only ones available IV?
MOA - irreversibly bind to the gastric H+/K+/ATPase pump in parietal cells, which blocks gastric acid secretion.
Before breakfast (at least 60 minutes before):
- esomeprazole (Nexium)
- lansoprazole (Prevacid)
- omeprazole (Prilosec)
- pantoprazole suspension (Protonix) - 30 mins prior
Without regard to meals:
- dexlansoprazole (Dexilant)
- pantoprazole tablet (Protonix)
Warnings
- C. diff
- hypomagnesemia
- bone fractures
- vit B12 deficiency
- PPIs all inhibit CYP2C19, which may diminish effect of clopidogrel (do NOT use omeprazole or esomeprazole w/ clopidogrel)
Available IV:
- pantoprazole
- esomeprazole
What is the max duration that PPIs should be used in the elderly, according to the Beers criteria?
Should not be used beyond eight weeks in elderly patients unless there is a clear indication (ex. high risk for GI bleed due to NSAIDs or demonstrated need for maintenance treatment)
Which H2RAs and PPIs are OTC (2,3), which come in ODT formulation (0,2), oral solution/suspension (2,3), and injection (1,2)?
OTC
- H2RA: famotidine, cimetidine
- PPI: omeprazole, esomeprazole, lansoprazole
ODT
- PPI: lansoprazole, omeprazole
Oral solution/suspension
- H2RA: famotidine, cimetidine
- PPI: (packets for suspension) esomeprazole, omeprazole, pantoprazole
Injection
- H2RA: famotidine
- PPI: esomeprazole, pantoprazole
Although metoclopramide has no role in GERD management, when is it most commonly used? What is its MOA, when is it dosed, when should dose be reduced? What is 1 boxed warning and 3 warnings?
Most commonly used when patients have coexisting gastroparesis
MOA - dopamine antagonist. It enhances the response to acetylcholine in the upper GI tract, causing increased motility.
Dosing: before meals and at bedtime.
- decrease dose 50% when CrCl < 60 mL/min
Boxed warning: tardive dyskinesia
Warnings: EPS (including acute dystonia), parkinsonian-like symptoms, AVOID use in patients with Parkinson disease
What 3 drugs must be AVOIDED completely with H2RAs and PPIs since H2RAs and PPIs increase pH of the gut?
- risedronate (Atelvia)
- rilpivirine
- velpatasvir/sofosbuvir (Epclusa)
What are the differences with duodenal vs. gastric ulcers in regards to when the pain is worse and how food effects it?
Duodenal - usually due to H. pylori
- pain is typically worse 2-3 hours after eating (when stomach is empty)
- eating food or taking antacids lessens the pain
Gastric - usually due to NSAIDs
- eating generally worsens the pain
What drugs make up bismuth quadruple therapy? What is the duration of treatment? In what pt populations should this regimen NOT be used?
bismuth quadrule therapy - should be used 1st line!!
- bismuth subsalicylate 300mg QID
- metronidazole 250-500mg QID
- tetracycline 500mg QID
- PPI BID
(3-in-1 product - Pylera (bismuth subcitrate potassium 420mg + metronidazole 375mg + tetracycline 375mg) QID + PPI BID)
Duration 10-14 days
Do not use in pts with alcohol use (metronidazole) or pregnant population (tetracycline)
What drugs make up concomitant therapy for H. pylori? What is the duration of treatment? When would we use this?
concomitant therapy - use if local resistance rates to clarithromycin are low (<15%) and no previous macrolide exposure
- amoxicillin 1g BID
- clarithromycin 500mg BID
- metronidazole 500mg BID
- PPI BID
Duration is 10-14 days
What drugs make up clarithromycin triple therapy? What is the duration of treatment? When would we use this? What if the pt has a penicillin allergy?
clarithromycin triple therapy - use if local clarithromycin resistance is low (<15%) and no macrolide exposure
- amoxicillin 1g BID
- clarithromycin 500mg BID
- PPI BID (or esomeprazole 40mg QD)
(3-in-1 - Prevpac (amoxicillin + clarithromycin + lansoprazole)
Duration is 14 days
If penicillin allergy: replace amoxicillin with metronidazole
What are 5 risk factors for NSAID-induced ulcers?
- age > 60 years old
- history of PUD (including H. pylori-induced)
- high-dose NSAIDs
- using > 1 NSAID
- concomitant use of anticoagulants, steroids, SSRIs, or SNRIs
What are the differences between ulcerative colitis and crohn’s disease is regard to diarrhea, fistulas/strictures, location, depth, and pattern?
Diarrhea:
- UC: bloody
- CD: bloody or non-bloody
Fistulas/strictures:
- UC: uncommon
- CD: common
Location
- UC: colon (especially rectum)
- CD: entire GI tract
Depth
- UC: superficial
- CD: transmural
Pattern:
- UC: continuous
- CD: non-continuous, “cobblestone” appearance
What lifestyle measures and natural products may be helpful for IBD management?
- eating smaller, more frequent meals that are low in fat and dairy
- drink plenty of water
- may use antidiarrheals or antispasmodic drugs
- vitamin supplements to prevent deficiencies related to malabsorption
- probiotics (Lactobacillus or Bifidobacterium infantis) can reduce abdominal pain, bloating, etc.
What is the treatment for mild and mod-severe crohn’s disease?
mild disease of ileum and/or right colon:
- oral budesonide for ≤ 3 months, then d/c or change to a thiopurine or methotrexate
mod-severe:
- preferred treatment: anti-TNF agent w/ or w/o methotrexate or a thiopurine, IL receptor antagonist, integrin receptor antagonist
- alternative: janus kinase inhibitor, integrin receptor antagonist
What is the treatment for mild and moderate-severe ulcerative colitis?
mild:
- mesalamine (5-ASA): rectal preferred if distal disease, rectal +/- oral if extensive disease
mod-severe:
- preferred: anti-TNF agents w/ or w/o thiopurine, IL receptor antagonist, integrin receptor antagonist
- alternative: janus kinase inhibitor, oral sphingosine-1-phosphate receptor modulators
what is the brand name of budesonide? What is the signifiance of budesonide having extensive first pass metabolism? What drug interaction is pertinent?
budesonide (Entocort EC, Uceris)
Due to budesonide’s extensive first pass metabolism, it has limited systemic exposure than other oral steroids
Budesonide is a major substrate of CYP3A4. Caution for inhibitors of CYP3A4
What is the brand name of these mesalamine ER formulations: ER capsules, ER tablets, enema, suppository? For the suppository and enema, how long should they be retained when administering? What is 1 contraindication?
ER capsules (Pentasa)
ER tables (Asacol HD)
Enema (Rowasa) - retain in the rectum overnight
Suppository (Canasa) - retain for at least 1-3 hours
Contraindication:
- hypersensitivity to salicylates or aminosalicylates
What are 2 thiopurines? What is one warning?
azathioprine
mercaptopurine
azathioprine warning: pts with a genetic deficiency of thiopurine methyltransferase (TPMT) and at an increased risk for myelosuppression. Consider TMPT testing before starting
What is the brand name of natalizumab, what frequency is it dosed and when should it be d/c’d? What are 2 boxed warnings?
natalizumab (Tysabri)
- dosed every 4 weeks
- discontinue if no response by 12 weeks
Boxed warnings
- progressive multifocal leukoencephalopathy (PML)
- only available through the REMS TOUCH Prescribing program
