LECTURES 63 & 64 - GERD / PUD Flashcards
(124 cards)
1
Q
Define GERD
A
“gastroesophageal reflux disease”
Symptoms of complications resulting from refluxed stomach contents into the esophagus or beyond, into the oral cavity (including the larynx) or lung
2
Q
Describe the symptom based clinical presentation of GERD
A
Reflux chest pain
Heartburn
Regurgitation / belching
(+ esophageal tissue injury)
3
Q
Describe the extraesophageal clinical presentation of GERD
A
Chronic cough
Laryngitis
Wheezing
Asthma
4
Q
List ALARM SYMPTOMS of GERD
A
Weight loss
Bleeding
Dysphagia
Odynophagia (painful swallowing)
refer immediately, no OTC
5
Q
What is the most useful tool for diagnosis of GERD?
A
Clinical history: identify sx, triggers, risk factors
6
Q
List general risk factors for GERD
A
Pregnancy
Obesity
Tobacco smoking
Delayed gastric emptying
Medication & food triggers
Comorbid conditions
Genetic predisposition
7
Q
List direct food irritants for GERD
A
Spicy foods
Orange juice
Tomatoes
Coffee
8
Q
List direct medication irritants for GERD
A
Aspirin
Bisphosphonates
NSAIDs
Iron
Quinidine
Potassium chloride
9
Q
List foods that decrease LES pressure in pts with GERD
A
Fatty foods
Chocolate
Coffee, tea, soda
Garlic & onions
Chili pepper
Alcohol
Peppermint & spearmint
10
Q
List medications that decrease LES pressure in pts with GERD
A
Anticholinergics
Barbiturates
Caffeine
DHP CCB
Dopamine
Estrogen & progesterone
Nicotine
Nitrates
Tetracycline
11
Q
List possible complications from GERD
A
Erosive esophagus
Stricture
Barrett’s esophagus
Esophageal adenocarcinoma
12
Q
List signs & symptoms of GERD in pediatric pts
A
Refusing to eat
Wheezing / Coughing
Dental erosion
Recurrent regurgitation
Irritability
13
Q
List signs & symptoms of GERD requiring additional investigation in pediatric pts
A
Weight loss
Fever
Seizure
Persistent vomiting / diarrhea
14
Q
List possible medications for treatment of GERD
A
- Antacids
- Histamine-2 Receptor Antagonist (H2RAs)
- Proton Pump Inhibitors (PPIs)
15
Q
What is the role of antacids in the treatment of GERD?
A
Neutralizes gastric acidity
Onset → 5 minutes
Duration → 20-60 minutes
16
Q
List common salts used in antacids
A
calcium
magnesium
aluminum
17
Q
List antacid salts that can cause constipation
A
calcium
aluminum
18
Q
List antacid salts that can cause diarrhea
A
magnesium
19
Q
List ADRs of calcium
A
milk-alkali syndrome
20
Q
List ADRs of magnesium
A
accumulation
21
Q
List ADRs of aluminum
A
confusion / neurotoxicity
22
Q
List drugs that can interact with antacids
A
Fluoroquinolones
Tetracyclines
Antifungals (azoles)
Levothyroxine
Iron
Steroids
Digoxin
HIV medications
23
Q
How can pts avoid antacid drug interactions?
A
Take medications 2 hours before OR 6 hours after antacids
24
Q
Describe the single-element agent that contains calcium
A
Calcium Carbonate (Tums)
2-4 tabs PRN up to 4x/day
MAX - 16 tabs/day
25
Describe the single-element agent that contains Magnesium
Magnesium Hydroxide (Milk of Magnesia, Phillip’s)
5-15 mL PRN up to 4x/day
MAX - 60 mL/day
26
List combination antacids that can be used to treat GERD
Aluminum + Magnesium
(Maalox, Gaviscon)
Aluminum + Magnesium + Simethicone
(Mylanta classic, Maalox Advanced Max strength)
Calcium + Magnesium
(Rolaids, Mylanta Supreme/Ultra)
Calcium + Simethicone
(Alka-Seltzer heartburn & gas, Tums gas relief)
27
Describe the dosing regimen of Maalox (aluminum + magnesium)
10-20 mL PRN - or - at meals + bedtime up to 4x/day
MAX - 80 mL/day
28
Describe the dosing regimen of Gaviscon (aluminum + magnesium)
2-4 tabs OR 10-20 mL at meals + bedtime 4x/day
MAX - 16 tabs/day
29
List other PRN medications that can be used to treat GERD
- Gas-X (simethicone)
- Alka-Seltzer (sodium bicarbonate + aspirin + citric acid)
- Pepto-Bismol (bismuth subsalicylate)
30
Describe how H2RAs treat GERD
Reversible inhibition of histamine receptors in the parietal cells
Used PRN -or- scheduled
Onset → 60 minutes
Duration → 4-6 hours
31
List H2RA medications that can be used to treat GERD
Famotidine (Pepcid, Zantac 360)
Cimetidine (Tagamet)
32
Describe the dosing regimen of Cimetidine (Tagamet) for the treatment of GERD
20 mg QD up to 30 minutes before trigger foods
MAX: 400mg/day
**Rx & OTC**
33
Describe the dosing regimen of Famotidine (Pepcid, Zantac 360) for the treatment of GERD
OTC: 10-20 mg BID (max = 40 mg/day)
If sx persists after 2-4 weeks → increase to 20 mg BID for 2 weeks
(switch to PPI if sx continue to persist)
34
Which H2RA is not commonly used to treat GERD due to drug-drug interactions?
Cimetidine (Tagamet)
**Interactions with CYP - 1A2, 2C9, 2D6, 3A4**
35
List common side effects of H2RAs used for treatment of GERD
- Dizziness or Fatigue
- Constipation or Diarrhea
- Somnolence, Confusion, Delirium
- Agitation
- B-12 deficiency - with long term use
36
What can occur with long-term use of H2RAs?
Tachyphylaxis
37
According to BEERs criteria, what should be considered when choosing to treat GERD with H2RAs
Avoid in pts with OR at high risk of delirium
38
Which drug class is more effective in the treatment of GERD: PPIs or H2RAs & why
PPIs -- H2RAs have a shorter DOA
39
Specifically, what symptoms of GERD do H2RAs treat?
nocturnal symptoms
40
Which H2RA is more effective in the treatment of mild-moderate GERD?
All H2RAs are considered equally efficacious
41
Describe how PPIs can be used in the treatment of GERD
Irreversible inhibition of H+/K+ ATPase
Onset —> 2-3 hours
Duration —> 24 hours
42
List PPI medications that can be used in the treatment of GERD
Esomeprazole (Nexium)
Lansoprazole (Prevacid)
Omeprazole (Prilosec)
Dexlansoprazole (Dexilant) → Rx only
Pantoprazole (Protonix) → Rx only
Rabeprazole (AcipHex) → Rx only
43
List PPI medication for the treatment of GERD that should be taken 60 minutes before meals
Esomeprazole (Nexium)
Pantoprazole (Protonix) → Rx only
44
List PPI medication for the treatment of GERD that should be taken 30-60 minutes before meals
Lansoprazole (Prevacid)
Omeprazole (Prilosec)
45
List PPI medication for the treatment of GERD that can be taken without regard to meals
Dexlansoprazole (Dexilant) → Rx only
46
Describe the dosing regimen for esomeprazole (Nexium)
OTC 20 mg daily X 14 days
may repeat course in 4 months if needed
Rx IV / PO: 20-40 mg daily
46
List PPI medication for the treatment of GERD that should be taken 30 minutes before meals
Rabeprazole (AcipHex) → Rx only
47
Describe the dosing regimen for lansoprazole (Prevacid)
OTC: 15 mg daily X 14 days
may repeat in 4 months prn
Rx: 15-30 mg daily
**ODTs available**
48
Describe the dosing regimen for omeprazole (Prilosec)
OTC: 20 mg daily X 14 days
can repeat in 4 months
Rx: 10-40 mg daily
49
Describe the dosing regimen for dexlansoprazole (Dexilant)
Dual release formulation
onset at 1-2 hours, then 4-5 hours
Rx w/o complications
30 mg daily
Rx w/ complications
60 mg daily X 8 weeks, then 30 mg indefinitely
50
Describe the dosing regimen for pantoprazole (Protonix)
PO Rx: 20-40 mg daily
IV Rx: 40 mg daily
**onset 15-30 minutes**
-- most common PPI on hospital formularies --
51
Describe the dosing regimen for rabeprazole (AcipHex)
Rx: 10-20 mg daily
52
Name an important counseling point for pantoprazole (Protonix)?
Tablet cannot be crushed / altered
53
List drugs that have an increased effect due to PPI usage
Methotrexate
Phenytoin
Warfarin
54
List drugs that have an decreased effect due to PPI usage
Iron
Bisphosphonates
HIV/HCV drugs
Clopidogrel
55
List common short-term side effects of PPIs used to treat GERD
- headache, dizziness
- diarrhea, flatulence
- nausea, abdominal pain
- enteric infections
- community-acquired pneumonia
56
List common long-term side effects of PPIs used to treat GERD
- Hypomagnesemia
- Bone density decrease / fractures
- Vitamin B12 deficiency
- Chronic kidney disease (CKD) - rare
57
Which dosage form is preferred for PPIs used for the treatment of GERD?
Use PO if able !!
IV formulation is just as effective as PO
58
Which PPI is more effective for the treatment of GERD?
All PPIs are considered equally efficacious
59
How should the treatment plan be adjusted for pts that don't respond to an initial PPI trial?
Pts should be switched to a different PPI with lowest effective dose
60
How should dosing be adjusted for pts that FAIL once daily max-tolerated dose PPIs
START with lowest dose QD, then either increase dose OR given lowest dose BID
61
How should PPIs be d/c after long-term use?
recommended to taper therapy
62
According to BEERs criteria, what should be considered when choosing to treat GERD with PPIs
Lower risk of SEs related to BEERs criteria than H2RAs
63
Explain GERD treatment for lactating pts
PPI’s & H2RAs are present in breastmilk BUT low risk to infants at standard doses
64
Explain the preferred treatments for pregnant pts
1st → Lifestyle modifications
2nd → Antacids & Sucralfate
3rd → H2RAs, reserved for complications of GERd / treatment failure
Last → PPI
65
List non-pharmacological treatment options for pediatric pts with GERD
- Thickening formula / foods
- Decreasing volume of intake
- Milk-free diet
- Positioning therapy
66
Describe the dosing & correct usage of PPIs & H2RAs for pediatric pts with GERD
Treat for 4-8 weeks
Only for diagnosed GERD or esophagitis
67
Describe the dosing & correct usage of antacids for pediatric pts with GERD
Should not use chronically
Do not use aluminum or bismuth subsalicylate containing antacids in children < 12 years !!
68
List lifestyle modifications that can be used for the treatment of GERD
- Weight loss (overweight / obese)
- Avoiding meals before bed
- Avoid tobacco / alcohol
- Avoid triggers
- Elevate the head of bed
69
List prn medication options for the treatment of GERD
Antacids and/or H2RAs
(separate or combination therapy)
70
List scheduled medication options for the treatment of GERD
PPIs and/or H2RAs
(separate or combination therapy)
71
Describe Antacids + H2RAs as combination therapy for the treatment of GERD
Helpful for heartburn after eating from different onsets
Pepcid AC (famotidine + calcium carbonate & Mg)
72
Describe PPIs + H2RAs as combination therapy for the treatment of GERD
- Nighttime administration of a single H2RA dose can help with nocturnal acid production
- H2RAs can also help with breakthrough heartburn
73
What qualifies pts for surgery to treat GERD?
- Long-term medication management is undesirable
- Symptoms or mucosal damage persist despite appropriate pharmacologic therapy
- Significant EGJ disruption exists (hiatal hernia)
74
List the goals of GERD management
Prevention & treatment
Neutralize acid
Reduce gastric acid secretion
75
When should pts be referred for treatment of GERD
- Alarm symptoms present
- 14 day trial of OTC product w/ no symptom relief
76
What qualifies pts for OTC treatment of GERD?
- No alarm symptoms
- Mild-moderate symptoms
- New onset
- Identified triggered minimized
77
Define PUD
"peptic ulcer disease"
Large ulcers (>/= 5 mm) that extend into the muscularis mucosa
Types of ulcers:
Gastric
Duodenal
78
List common etiologies of PUD
H. pylori
NSAIDs
Stress (critical illness)
79
Which etiologies cause chronic PUD?
H. pylori
NSAIDs
80
Describe the clinical presentation of NSAID-induced PUD
- Chronic PUD
- Commonly in stomach
- Less dependent on intragastric pH
- Often asymptomatic
- More severe GI bleeding
81
Describe the clinical presentation of stress-induced PUD
- Acute PUD
- Commonly in stomach
- Less dependent on intragastric pH
- Asymptomatic
- More severe GI bleeding
82
Describe how food can help determine the location of peptic ulcers?
Duodenum ulcer(s) - pain relieves
Stomach ulcer(s) - pain worsens
83
List possible symptoms of PUD
- Epigastric pain
- Nausea & Vomiting
- Belching, Heartburn
- Bloating, Abdominal Fullness
- Weight loss / anorexia
- Nocturnal pain
**Variability in symptoms**
84
List risk factors for PUD
- H. pylori infection
- NSAID use
- Gastric acid hypersecretion
- Cigarette smoking
- Physiologic stress
- Dietary factors
85
List risk factors for NSAID-induced ulcers
- Age > 65
- Previous peptic ulcer
- Previous ulcer related GI complication
- Multiple NSAID use
- NSAID related dyspepsia
- Concomitant used of aspirin, oral bisphosphonates, systemic corticosteroids, anticoagulation, antiplatelets, or SSRIs
- Smoking
- Alcohol consumption
86
List potential complications of PUD
GI bleed
GI perforation
GI obstruction
**can be life threatening**
87
List non-pharmacologic therapy options for treatment of PUD
- Reduce physiological stress
- Smoking cessation
- Avoid NSAIDs
- Avoid foods that cause dyspepsia
- Surgery
88
List ADRs caused by metronidazole
Avoid alcohol due to disulfiram-like reaction
89
List ADRs caused by amoxicillin
GI upset
90
List ADRs caused by tetracycline
Photosensitivity (sunscreen)
Avoid in children, may permanently stain teeth
91
List ADRs caused by rifabutin
Discoloration of urine / bodily fluids
GI upset
92
List ADRs caused by clarithromycin
QTC prolongation
Photosensitivity (sunscreen)
GI upset
93
What is the generally preferred regimen for the treatment of PUD caused by H. pylori
Bismuth Quadruple therapy (x 10 - 14 days)
94
List the components of Bismuth Quadruple therapy for the treatment of H. pylori-induced PUD
PPI BID
Bismuth Subsalicylate
Metronidazole
Tetracycline
95
List the brands available for Bismuth Quadruple therapy
Helidac → convenient packaging
Pylera → 3-in-1 capsule
** PPI taken separately **
96
List PPIs commonly used for H. pylori PUD
Omeprazole (Prilosec) 20 mg
Pantoprazole (Protonix) 40 mg
Esomeprazole (Nexium) 20-40 mg
Lansoprazole (Prevacid) 30 mg
97
How long should PPIs be used to treat H. pylori PUD?
PPIs not usually necessary beyond 2 weeks of use (should not be continued indefinitely)
98
Describe the used of H2RAs in the treatment of H. pylori PUD
H2RA should NOT be substituted for a PPI unless the pt cannot tolerate a PPI
99
List other potential treatment options for H. pylori PUD
Rifabutin triple
Vonoprazan dual
Vonoprazan triple
100
Describe the components of Vonoprazan dual therapy for the treatment of H. pylori PUD
Vonoprazan 20 mg BID
Amoxicillin 1G q8h
x14 days
101
Describe the components of Vonoprazan triple therapy for the treatment of H. pylori PUD
Vonoprazan 20 mg BID
Amoxicillin 1G q8h
Clarithromycin 500 mg BID
x14 days
102
Describe the components of Rifabutin triple therapy for the treatment of H. pylori PUD
Omeprazole 40 mg q8h
Amoxicillin 1 gm q8h
Rifabutin 50 mg q8h
x14 days
103
Describe prevention strategies for NSAID-induced PUD
- Co-therapy with additional agents (PPIs, H2RAs, misoprostol)
- Utilize COX-2 selective NSAIDs (celecoxib)
- Utilize least GI toxic NSAID at lowest effective dose (naproxen)
104
List PPIs that can be used in the treatment of NSAID-induced PUD
Omeprazole 40 mg daily
Pantoprazole 40 mg daily
Esomeprazole 40 mg daily
Lansoprazole 30 mg daily
105
List H2RAs that can be used in the treatment of NSAID-induced PUD
Famotidine
Cimetidine
106
List the side effects of vonoprazan
Bloating
Stomach pain
Nausea
Diarrhea
Stomach inflammation
UTI
107
How does sucralfate treat PUD?
Forms a physical barrier over open ulcer to protect it from further insult
108
List the SEs of sucralfate
Constipation
Metallic taste
Aluminum toxicity in chronic renal failure
109
Describe the dosing regimen of sucralfate
1g QID before meals & at bedtime
Administer on empty stomach 2 hours before OR 4 hours after other medications
110
List the goals of care for PUD
Relieve ulcer symptoms
Heal the ulcer
Prevent recurrence
Reduce ulcer-related complications
111
List PUD treatment considerations
Avoid antimicrobials the pt has already taken
Consider allergies & intolerances
Pt adherence
112
List factors that predict H. pylori PUD treatment outcomes
Antibiotic resistance
Poor medication adherence
Short duration of therapy
High bacterial load
113
Name the preferred PUD treatment(s) for treatment-naive pts
Optimized bismuth quadruple
114
Name the empiric PUD treatment(s) for treatment-experienced (salvage) pts
Optimized bismuth quadruple
Rifabutin triple
115
List other potential treatment options for H. pylori PUD for treatment-naive pts if the preferred treatment is not an option
Rifabutin triple
Vonoprazan dual
116
Name the empiric H. pylori PUD treatment(s) for treatment-experienced (salvage) pts with proven antibiotic sensitivity
Optimized bismuth quadruple
Rifabutin triple
Vonoprazan triple
Levofloxacin triple – after 1st line failed
117
What is the only option for treatment of H. pylori PUD for pts with a penicillin allergy?
Optimized bismuth quadruple
118
What is the next step for treatment of H. pylori PUD for pts with a penicillin allergy if the preferred tx is not an option?
consider referral for formal penicillin allergy testing and/or desensitization
119
List the potential next steps for treatment failure of a pt with H. pylori PUD
- Second-line, or “salvage”, regimen should utilize antibiotics NOT used in initial therapy
- Consider antibiotic resistance patterns in the local area
- Extend duration of treatment to 10-14 days
- Perform a penicillin skin test if pt has documented allergy
- Refer to gastroenterologist
120
Describe the appropriate treatment plan for pts with NSAID-induced PUD that CAN stop their NSAID use
PPI !!
H2RA, or sucralfate for EIGHT (8) weeks
121
Describe the appropriate treatment plan for pts with NSAID-induced PUD that continue their NSAID use
- PPI for TWELVE (12) weeks
- Use LOWEST effective dose of NSAID
- May consider continuing PPI
122
List the key takeaways for H. pylori induced ulcers
- acid suppression & antibiotics
- PPIs typically dosed BID
- treat: 10-14 days
- can finish ulcer treatment with PPI for at least 14 more days
123
List the key takeaways for NSAID-induced ulcers
- prevention is KEY
- PPIs are dosed daily
- treat for 8 weeks if NSAID stopped, 12 weeks if continued
