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GERD & PUD Flashcards

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1
Q

What xterizes GERD?

A

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

And allows the BACKFLOW of the stomach contents

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2
Q

List typical sx of GERD?

A

Heartburn

Hypersalivation

Regurgitation

Acid taste in mouth

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3
Q

List alarm conditions in which patients require further testing

A

Chest pain, dysphagia

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4
Q

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

A

Concern about

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

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5
Q

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

A

Increased risk of osteoporosis and fractures with long-term use

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6
Q

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?

A

Cimetidine (due to drug-drug int, ADRs)

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7
Q

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

A

Risk of worsening:

Dementia

Delirium/confusion

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8
Q

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

A

False!

They are dose adjusted in renal impairment

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9
Q

List recommended non-pharmacologic (lifestyle) tx

A

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

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10
Q

List agents used in GERD pharmacologic therapy

A

Antacid

Histamine (H2) Receptor Antagonists (H2RAs)

Proton Pump Inhibitors (PPIs)

Cytoprotective agents

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11
Q

MOA of antacids?

A

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

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12
Q

List drugs under antacids

A

Calcium (Tums)

Magnesium (Phillips Milk of Magnesia (MOM))

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

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

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13
Q

Brand name of Calcium (antacid)?

A

Tums

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14
Q

Brand name of Magnesium (antacid)?

A

Phillips Milk of Magnesia (MOM)

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15
Q

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

A

Maalox

Mylanta

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16
Q

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

A

Maalox Max

Mylanta Max Strength

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17
Q

What’s the drug of choice during pregnancy?

A

Antacids

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18
Q

Reduced absorption due to chelation is seen in antacid +?

A

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

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19
Q

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

A

Use antacids 2hrs B4

And

4-8 hrs after

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20
Q

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

A

Doxycycline and Minocycline

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21
Q

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

A

True

They usually only last about 1-2 hrs

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22
Q

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

A

Tums (calcium) only

Avoid Mg and Al

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23
Q

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

A

Al

T4 d/c Al pdts

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24
Q

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

A

Mg-containing pdts

Use Tums - contains Ca only

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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
105
What's GERD?
GERD is a condition in which the stomach contents leak backwards into the esophagus

GI 363 (10 decks)

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