GERD & PUD Flashcards
(114 cards)
1
Q
What type of cell secretes HCl
A
Parietal cells
2
Q
HCl is secreted in response to what 3 physiologic stimuli?
A
- ACh
- Histamine
- Gastrin
3
Q
Which of the 3 physiologic stimuli is most important clinically?
A
Histamine
4
Q
What type of transmitter is histamine?
A
Paracrine
5
Q
What does histamine bind?
A
H2 receptors on basolateral membrane of parietal cells
6
Q
H+ ions are actively secreted in exchange for….
A
K+ (by Na+/K+ pump on surface of parietal cells)
7
Q
Acid secretion is driven by what nerve
A
Vagus n.
8
Q
What is the most frequent GI condition encountered in outpt. setting
A
GERD (20% of population)
9
Q
Sx of GERD
A
- Heartburn & regurg (classic sx)
- Dyspepsia (early satiety, gutt rot)
- Chest pain
- Belching
- Dysphagia
- Voice changes
- Chronic cough
10
Q
Complications of GERD
A
- Barrett’s esophagus
- Strictures
- Bleeding
11
Q
What are examples of alarm symptoms?
A
Dysphagia, GI bleed, anemia, wt. loss, persistent vomiting
12
Q
What diagnostic tool is used to evaluate alarm symptoms?
A
Endoscopy
13
Q
What other patient population is endoscopy recommended for?
A
Pts at high risk for complications
- Those who do not respond to 4-8 wk trial of PPI
- Men >50 w/ chronic GERD (>5yr) who have additional RF for Barrett’s (e.g. obesity, hiatal hernia)
14
Q
What are examples of lifestyle modifications used in GERD mgmt?
A
- Avoid lying down for at least 2 hours after eating or drinking
- Elevating HOB
- Wt. loss
15
Q
What lifestyle modification is no longer recommended for GERD pt?
A
Avoiding foods thought to trigger reflux e.g. chocolate, caffeine, alcohol, spicy foods
16
Q
Tx regimen for mild, infrequent GERD
A
Antacid or H2RA
17
Q
Tx regimen for severe, frequent GERD OR those whose sx are inadequately controlled on antacid or H2RA
A
PPI
18
Q
How many weeks of PPI therapy is recommended prior to de-escalation?
A
8 wks
19
Q
In what populations is PPI de-escalation not recommended?
A
- Pt. on chronic ASA therapy
- Barrett’s esophagus
20
Q
Pts. on a PPI (PO QD) who continue to have sx, may benefit from what alteration to their tx regimen?
A
- BID therapy
- Switching to another PPI
21
Q
What is recommended for pt. who still have noctural sx despite BID PPI therapy?
A
Addition of H2RA therapy
22
Q
Pts who have recurrent sx ater stopping a PPI may respond to what?
A
- Another course of tx
- On-demand PPI tx
23
Q
What type of tx regimen is recommended for the healing of erosive esophagitis?
A
PPI x8wks (almost all pt. will have relapse within 6mo of stopping tx, most will require indefinite tx)
24
Q
Most antacids are comprised of various salts including:
A
- Al(OH)3
- CaCO3
- Mg(OH)2
25
Common antacid preparations
- Aluminum hydroxide + magnesium hydroxide
- Calcium carbonate + magnesium hydroxide
- Calcium carbonate
26
Antacid MOA
- Neutralizes gastric acidity (↑ gastric pH)
| - Inhibits proteolytic activity of pepsin when gastric pH >4
27
Clinical indications for antacids
PRN for dyspepsia/GERD
28
Drug interactions with antacids
- ↓ TCC & FQ absorption (form nonabsorbable complexes)
| - ↓ absorption of various agents (itra/ketoconazole, Fe2+, digoxin, phenytoin) d/t "alkalization" of stomach
29
Al(OH)3 ADRs
- Hypophosphatemia
- Aluminum intoxication
- Constipation
30
Aluminum intoxication could cause what in CKD pts.?
Encephalopathy, seizure, coma
31
CaCO3 ADRs
- Constipation
| - Milk-Alkali syndrome
32
What is Milk-Alkali syndrome?
HA, nausea, irritability, weakness, hypercalcemia, metabolic alkalosis, & hypophosphatemia w/ large doses or in CKD pts.
33
Mg(OH)2 ADRs
- Hypermagnesemia
| - Laxative effects
34
What is sucralfate?
Aluminum hydroxide complex of sucrose
35
Sucralfate MOA
Forms a complex by binding with positively charged proteins in exudates; viscous paste-like/adhesive provides protective coating
36
Clinical indications for sucralfate
- GERD/PUD (minimally used)
- NSAID-induced mucosal damage
- Prevention of stress ulcers
- Suspension used topically for tx of stomatitis d/t CA chemo/other causes
37
Interactions for sucralfate
↓ absorption of itra/ketoconazole, digoxin, phenytoin, warfarin, theophylline, TTC, FQ
- Take other meds 2 hrs before
38
Why is taking medications 2 hrs before sucralfate difficult?
Sucralfate is a QID drug
39
Sucralfate ADRs
- Constipation
| - Aluminum toxicity in CKD pts
40
Examples of 1st gen H2RAs
- Cimetidine
| - Ranitidine
41
Examples of 2nd gen H2RAs
- Famotidine
| - Nizatidine
42
What H2RA is the FDA investigating in regards to NMDA content?
Ranitidine
| - Products have been pulled from the market
43
H2RA MOA
Inhibit gastric secretion by blocking histamine receptors on parietal cells
- Reduction in basal gastric acid secretion > food-stimulated after a single dose
44
Are H2RAs good for regular use or prn use
PRN
45
What H2RA should we encourage the use of?
Famotidine
46
Clinical indications for H2RAs
- Dyspepsia/GERD/PUD
- SUP in critically ill pt.
- Gastric hypersecretory states (PPI >)
47
Decreased GI acidity with H2RAs may lead to what?
HAP/VAP & CDI
48
Drug interaction with H2RAs
↓ absorption of itra/ketoconazole, digoxin, phenytoin, Fe2+
49
Which H2RA is a weak/moderate inhibitor of almost every isoenzyme?
Cimetidine
| - Use discouraged because of this
50
H2RA ADRs
- Acid rebound (stopping med leads to a surge; mitigated with taper, antacids for breakthrough)
- Confusion in cognitively impaired/demented elderly pt.
51
Cimetidine ADRs
- ED (libido)/gynecomastia (chronic use)
- Drug fever
- Agranulocytosis
52
Examples of PPIs
- Omeprazole*
- Esomeprazole
- Pantoprazole*
- Rabeprazole
- Lansoprazole*
- Dexlansoprazole
* what we use for the most part
53
What PPIs are available IV>
- Esomeprazole
| - Pantoprazole
54
Why don't we use the IR formulation of omeprazole that's buffered by NaHCO3?
Too much Na+
55
PPI MOA
Suppresses gastric basal & food-stimulated secretion by inhibiting parietal cell H+/K+ ATP pump
56
When should PPIs be taken/administered?
30-60 minutes before 1st meal
57
Why should PPIs be taken/administered after a prolonged fast?
Amount of H-K-ATPase present in parietal cell is greatest after a prolonged fast
58
Clinical indications for PPIs
- GERD ( role for chronic dz w/ mild-mod sx; intermittent vs. "on-demand" vs continuous)
- PUD +/- bleeding - standard of care!
- SUP in critically ill pt.
- Gastric hypersecretory states - standard of care!
- H. pylori infection
59
Indications for intermittent PPI dosing for GERD pt.?
Occasionally heart burn sx (every 3rd day)
60
Indications for "on-demand" PPI dosing for GERD pt.?
For new change in disease course
61
Indications for continuous PPI dosing for GERD pt.?
Pt. w/ complications (e.g. Barrett's, strictures)
62
Concerns with PPI use that contribute to decision making
- ↑ CDI
- CAP/HAP
- ↑ fx risk in PM women & pt. >50yo OR pts. on high dose for >1yr -> ↓ Ca+ absorption
- Hypomagnesia, iron or B12 deficiency (anemia?) r/t long-term use (>1yr)
63
What is our goal if we put a PPI on board?
Use the lowest effective dose for the shortest duration possible
64
Which PPIs are available OTC?
- Omeprazole
- Esomeprazole
- Lansoprazole
65
Do PPIs differ clinical for sx relief, esophagitis/ulcer healing etc?
nah
66
There is a risk of tolerance developing with H2RAs or PPIs?
H2RAs
67
What can we considering monitoring in a pt. on a PPI?
Mg+! @ baseline AND periodically in pt. on long-term therapy (>2wks) or those on diuretics, digoxin
68
PPI use should be avoided in what two populations?
1. Pt. on drugs that carry a known risk of TdP
| 2. Pt. with long QT syndrome
69
Do PPIs cause QT prolongation?
NO! The drug itself does not BUT it manipulates the absorption of cations
70
If extended drug therapy is indicated in a pt. that is taking a QT prolonging drug, what should monitor?
- Mg+
| - QT interval
71
PPIs are substrates of CYP___ & CYP___
CYP2C19; CYP3A4
72
Most PPIs are moderate inhibitors of CYP___
CYP2C19
73
What PPIs should we use concomitantly with CYP2C19 substrates, such as phenytoin & clopidogrel?
* Pantoprazole*, lansoprazole, dexlansoprazole
| - Omeprazole & esomeprazole may be problematic
74
Omeprazole moderately inhibits CYP___
CYP2C9 (caution w/ warfarin, phenytoin)
75
Other drug interactions w/ PPIs
- ↓ absorption of itra/ketoconazole, digoxin, phenytoin, Fe2+/Ca+/Mg+/B12
- ↓ MTX clearance
76
PPI ADRs (generally)
- Nosocomial inf
- Anemia
- Fx
- AIN -> CKD w/ long term use
77
What drug is a synthetic analog of prostaglandin E1?
Misoprostol
78
Misoprostol MOA
Gastric antisecretory agent w/ protective effects on GI mucosa
79
Use of misoprostol is CONTRAINDICATED in what pt. population?
Pregnant women (stimulates expulsion of ~products of conception~)
- Category X
- r/o possibility prior to use + contraception during use
80
Clinical indications fro misoprostol
- Prevention of NSAID-induced ulcers
- Treatment of PUD
- Various obstetric indications
81
Why os misoprostol not 1st line for tx of PUD?
Requires multiple daily doses & ADRs
82
Misoprostol ADRs
Diarrhea & abd pain
83
Why is heartburn so common in pregnancy? (up to 80%)
Prostaglandin mediated ↓ in LES tone
84
5 steps to treating GERD/PUD in pregnancy
```
Step 1: lifestyle modifications
Step 2: antacids
Step 3: sucralfate (if antacids fail)
Step 4: H2RA
Step 5: PPI considered (persistent sx on H2RA)
```
85
"Recommended" antacids in pregnancy
- Aluminum hydroxide + magnesium hydroxide
- Calcium carbonate
* regarded as safe, but watch for ADRs
86
Antacids to avoid in pregnancy
- Mg+ trisilicates
| - Sodium bicarb
87
What harm might Mg+ trisilicates cause to a fetus?
Nephrolithiasis, hypotonia, respiratory distress (chronic use/high doses)
88
What harm might sodium bicarb cause in pregnancy?
Materal/fetal metabolic alkalosis & fluid overload
89
What drugs/classes are category B?
- Aluminum hydroxide + magnesium hydroxide
- Sucralfate
- H2RA (ranitidine > *most data)
- PPIs (except omeprazole - C)
90
Examples of supplemental iron
- Ferrous sulfate (65-100 elemental iron/tab)
- Ferrous fumarate (65-100 elemental iron/tab)
- Ferrous gluconate (35 elemental iron/tab)
91
When should iron supplement be taken?
Best absorbed on empty stomach, but may be better tolerated w/ food (if GI upset occurs)
92
Iron supplements may cause ↓ absorption of....
- Bisphosphonates
- Levodopa
- LT4
- FQs
- TTCs
93
What other meds ↓ absorption of iron supplements?
- Ca+/Al/Mg+ containing antacids
- H2RAs
- PPis
94
Dosing of iron:
100-200mg/day of ferrous sulfate or ferrous fumarate
| - Start 1 tab/d, titrate up to BID or TID over 1-2 wks if tolerated
95
What do we monitor 1x/mo in iron-deficient pt. on supplements?
Hgb
96
H. pylori can cause gastric inflammation & has been associated with what other pathologies
Gasritis, PUD, gastric adenocarcinoma, MALT
97
Eradication of H. pylori....
- Promote gastric healing
- Prevents recurrence of ulcers
- ↓ incidence of gastric CA
98
Testing for H. pylori
- Noninvasive: urea breath, stool antigen, serology
| - Invasive: endoscopy w/ bx
99
How to choose a regimen for tx of H. pylori
- Prior macrolide exposure?
- Allergies?
- Dosing convenience
- Cost?
100
What does TRIPLE therapy for H. pylori consist of?
PPI + clarithromycin + amox or metronidazole
101
Why is triple therapy falling out of favor?
Clarithromycin resistance
102
At what parameter of clarithromycin resistance would be an indication to move to quadruple therapy?
Clarithromycin resistance >15%
| - Local resistance patters, ABX resistance testing NOT widely available -> make the switch to quadruple therapy anyway
103
What does concomitant QUADRUPLE therapy for H. pylori consist of?
PPI + clarithromycin + amox + metronidazole or tinidazole
104
How often is concomitant QUADRUPLE therapy dosed?
BID
105
What does bismuth QUADRUPLE therapy for H. pylori consist of?
PPI + bismuth + TTC + metronidazole or tinidazole
106
How often is bismuth QUADRUPLE therapy dosed?
QID
107
How long do we treat w/ quAdruple therapy?
10-14d
108
What do we do post-quadruple therapy treatment?
"Cure documentation"
109
What can be used sometimes for dyspepsia or to distinguish GERD & CP in the ED?
GI cocktails
| - Do NOT rely on to r/o CP
110
What constitutes a GI cocktail?
Liquid antacid + viscous lidocaine +/- antispasmodic (e.g. Donnatal)
111
Adding Donnatal), lidocaine, or both to an antacid....
Does NOT seem work better for dyspepsia than an antacid alone (liquid antacid alone is recommended)
112
No good evidence that magic mouthwash is better than....
Homemade salt & sodium bicarb rinse
113
Two magic mouthwash recipes
1. Viscous lidocaine + diphenhydramine + liquid antacid (1:1:1)
2. BLM kit: Benadryl + Licocaine + Maalox (Al + Mg hydroxide) + simethicone ($$$)
114
Pt. ed for magic mouthwash
- Swish & SPIT for oral ulcers
- Swish & SWALLOW for pharyngeal or esophageal ulcers
- Use q4-6hrs PRN
- Hold in mouth for 1-2min
- Don't eat or drink for 30 min after
